Society for Education and the Advancement of Research in Connected Health The National Telehealth Research Symposium Abstracts November 11–13, 2020

Search Presentations

1. Cost Minimization Analysis of a Teledermatology Triage System in an Urban Safety‐Net Hospital

Adam Zakaria, BA¹, Theodore A. Miclau, MS², Toby Maurer, MD³, Kieron S. Leslie, MB, BS⁴, Erin Amerson, MD⁵

¹University of California, San Francisco School of Medicine, San Francisco, California, USA; ²Stanford University School of Medicine, Primary Care and Population Health, Stanford, California, USA; ³Department of Dermatology, Indiana University, Indianapolis, Indiana, USA; and ⁴Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA

Background: Teledermatology enables dermatologists to remotely triage and manage their patients. Previous analyses of teledermatology have demonstrated improved access to care, but inconsistent fiscal impact.

Methods: We applied patient and cost data to decision tree models in order to compare the average cost per new dermatology referral before and after implementation of teledermatology at the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG).

Results: The analysis captured 2,098 patients. The average cost per new dermatology referral was $517.68 in the conventional care model and $490.61 in the teledermatology model. Therefore, teledermatology led to a cost savings of $27.07 per patient.

Conclusions: Teledermatology led to cost savings within the ZSFG healthcare system, thus suggesting that other managed health care settings may benefit from using teledermatology to triage and manage patients

Presenting Author e‐mail: Adam.Zakaria@ucsf.edu

2. Remote Patient Monitoring for Pediatric Obesity Treatment

Crystal S. Lim, PhD, Crystal S. Lim, PhD, Laura Rutledge, MAMFTC, Shanda Sandridge, CPNP, Krista King, RD, Darryl J. Jefferson, MBA, Tanya Tucker, BSN, RN

University of Mississippi Medical Center, Jackson, Mississippi, USA

Background: The purpose of this study is to describe the initial implementation of a remote patient monitoring system (RPMS) to enhance care in an outpatient multidisciplinary pediatric obesity clinic.

Methods: RPMS results in improved health and reduced health care costs in adults but has not been evaluated in pediatric obesity. We implemented an open trial design to examine feasibility of a RPMS with youth (8‐17yo) attending a pediatric obesity clinic.

Results: To date, 33 patients have used the RPMS. Patients were Mage = 13.5 years old (SD = 2.39), primarily African American (66.7%), and morbidly obese (MBMI%ile = 99.03). On average the 11 patients who completed RPMS have lost weight (MΔweight = 0.05kgs).

Discussion: RPMS may be a promising and acceptable way to deliver evidence‐based pediatric weight management treatment to rural, underserved, and racially diverse youth.

Presenting Author e‐mail: cstacklim@umc.edu

4. Implementing a Tele‐Neurosurgery Program in rural New Mexico reduces unnecessary transfers and provides specialty services that were previously not available.

Susy Salvo‐Wendt, MSH¹, Howard Yonas, MD²

¹Summit Regional Medical Center, Pinetop-Lakeside, Arizona, USA and ²Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA

Background: The arrival of a patient with a fractured skull or an intracerebral bleed in a rural hospital emergency room most often means a costly transfer to a higher‐level hospital even when not indicated.

Methods: From monitoring NM ER records over a five‐year period, over 90% of patients with these types of injuries are transferred. A review of case logs reveals that over 70% of such transfers are discharged from tertiary care centers for observation.

Result: After virtually consulting on 252 rural patients we reduced the transfer rate to 13% with 50% of those patients needing surgical intervention. The 87% that did not transfer did well with no later transfer due to neurological deterioration.

Discussion: The key to sustaining integration of a neurosurgeon in an emergency telemedicine consult service is user friendly cloud‐based technology and sufficient reimbursement to cover the costs.

Presenting Author e‐mail: salvo.wendt@comcast.net

5. Asynchronous Telemedicine between Patients and Providers: A Systematic Review

Catanya Stager, MA, Todd Smith, PhD, Nathan Culmer, PhD, Hannah Meyer, Trey Clark, Abigail Fickel

University of Alabama, Tuscaloosa, Alabama, USA

Background: This systematic review (SR) of asynchronous telemedicine (AT) examines benefits and challenges of AT for patients, interventions, comparisons, outcomes with regard to the quadruple aim of medicine.

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, we searched databases for eligible articles, screened for studies with peer reviewed patient‐provider AT empirical designs, and coded the study results.

Results: We found 1,094 unduplicated relevant articles on AT. Study findings are coded for 1) patients, intervention, comparison, and outcomes (PICO) as well as, 2) cost, quality, care satisfaction, and well‐ being (quadruple aim) and 3) quality of the studies.

Discussion: This SR comprehensively identifies, appraises, and synthesizes AT solutions, their outcomes for patients, and their study design/quality, and this SR also locates gaps to help direct future studies.

Presenting Author e‐mail: cgstager@crimson.ua.edu

7. How to Develop a Great Systematic Literature Review Manuscript

Nathan Culmer, PhD, Catanya Stager, MS, Todd Smith, PhD

University of Alabama, Tuscaloosa, Alabama, USA

Background: Systematic reviews are powerful tools to assimilate data, assess the field and guide next steps–particularly in telehealth. Too few researchers use this methodology–in part due to lack of training.

Methods: This presentation will cover the four major components of conducting a systematic review: proper planning, effective literature searches, abstract reviews and data extraction. Appropriate tools, building teams and lessons learned will also be shared.

Results: By the end of this session, participants will understand the purpose of a systematic review, distinguish it from similar study types, identify needed review tools, and be able to conduct the necessary steps and processes to successfully complete one.

Discussion: A systematic review is a potent research and clinical tool. This session will equip participants with the needed knowledge, tools, and steps to begin their own research project using this methodology.

Presenting Author e‐mail: npculmer@ua.edu

10. Integration of Telehealth into a Nurse Triage Workflow within a Pediatric Connected Health System

Cynthia Zettler‐Greeley, PhD¹, Joanne Murren‐Boezem, MD, MPH², Patricia Solo‐Josephson, MD¹

¹Nemours Children’s Health System, Jacksonville, Florida, USA and ²Nemours Children’s Health System, Orlando, Florida, USA

Background: This study explored a pediatric health system’s integration of on‐demand telehealth into on‐call, primary care, triage nurse workflow and examined patient telehealth use after nurse recommendation.

Methods: Nurses educated families on telehealth as appropriate for the patient’s chief complaint during triage. Sample data included 115,000 patient‐families who contacted triage nurses during the study and 9 triage nurses, surveyed 3 years’ post‐integration.

Results: Initial retrospective data analysis indicated that 706 patients utilized telehealth within 48 hours of triage nurse recommendation. Triage nurse comments reflect positive experiences with telehealth and offer suggestions for improving workflow.

Discussion: This study demonstrates that telehealth can be incorporated into a triage nurse workflow. Triage nurses increased utilization by educating caregivers about the value and convenience of telehealth.

Presenting Author e‐mail: cynthia.zettlergreeley@nemours.org

11. Use of Telemedicine for Retinopathy of Prematurity Examination in a Level II NICU

Abhishek Makkar MD¹, Barbara Johnson¹, Michael McCoy¹, Kari Peterson¹, Michael R. Siatowski²

¹Department of Pediatrics, OUHSC, Oklahoma City, Oklahoma, USA and ²Department of Ophthalmology, Dean McGee Eye Institute, Oklahoma City, Oklahoma, USA

Background: Infants meeting criteria for level 2 NICU are currently being transferred from University of Oklahoma Medical Center NICU (Level IV) to Comanche County Memorial Hospital NICU (Level II) in Lawton OK (90 miles away) so they can be closer to home. Many infants who meet criteria for transfer require continued dilated fundus exams to detect Retinopathy of Prematurity (ROP) every 1‐2 weeks and cannot be transferred due to lack of an ophthalmologist with ROP expertise in the Lawton area. Recently, the AAP has recognized the use of telemedicine for remote evaluation as a potential means of ROP screening, but use of telemedicine as effective tool for ROP screening in satellite NICU’s is understudied. Objective: To evaluate feasibility, safety and cost‐effectiveness of utilizing telemedicine for ROP screening at a Level 2 NICU.

Methods: Retrospective chart review of infants who required tele‐ROP exam at a Level II NICU upon transfer from regional Level IV NICU. Patient demographics, and ROP findings were analyzed. Image quality from infants undergoing telemedicine was graded as Fair/Good/Excellent. Correlation of tele‐ROP and conventional in vivo ROP exam completed either at a Level IV NICU or in outpatient setting was performed. Cost savings was calculated by multiplying Hospital Cost Differential between two NICU’s and Total Patient Hospital Days from back transfer. Descriptive statistics were computed for demographic and clinical variables.

Results: Over a 2‐year period (July 2017‐June 2019), telemedicine was used to screen 26 infants for ROP. A total of 372 fundus images were captured during this period. 96% of images were graded as Good/Excellent and 4% were graded as Fair. Strong correlation was noted between final imaging done via telemedicine and subsequent conventional exam via indirect ophthalmoscopy. No patient developed referral‐warranted ROP. Overall our Tele‐ROP program allowed 484 patient hospital days that family spent in lower level NICU closer to home. At a cost differential of $500 per day this small pilot resulted in nearly $250,000 of savings in inpatient care.

Discussion: Telemedicine for ROP evaluation is feasible, safe & cost effective in a Level II NICU, and allows more patients to receive intensive care closer to home.

Presenting Author e‐mail: abhishek‐makkar@ouhsc.edu

12. Does Telehealth in Emergency Departments (EDs) lower ED Cost?

Dunc Williams, Jr, PhD, Annie Simpson, PhD, Kit Simpson, PhD, Dee Ford, MD, Richard Summers, MD

Organization, City, State, USA

Background: Since 2003, the University of Mississippi Medical Center (UMMC) has operated a robust telehealth emergency department (ED) network (TelEmergency) that enhances access to emergency medicine‐ trained providers at twenty participating rural hospitals. UMMC developed TelEmergency as a preventative measure for many financially‐constrained rural Mississippi hospitals. While previous work has shown that ED telehealth can improve various health outcomes, the literature is unclear as to whether ED telehealth services can be provided at lower costs than traditional in‐person ED services. The objective of this study was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals than similar comparison hospitals between 2010 and 2017.

Methods: A panel of data for 2010 – 2017 was constructed at the hospital‐level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital‐years) were compared to similar hospitals that did not offer TelEmergency from AR, GA, MS, and SC (n = 102; 766 hospital‐years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors.

Results: After controlling for ownership type, CAH‐status, time, and size, and compared to similar matched hospitals that did not provide TelEmergency, TelEmergency was associated with an estimated 31.4% lower total ED costs (statistically significant at p = 0.073).

Discussion: Through TelEmergency, UMMC maintained access to ED care in outlying rural MS communities while simultaneously providing that care at relatively lower costs.

Presenting Author e‐mail: wiljd@musc.edu

14. Rapid Implementation of Telemedicine in an Academic Movement Disorders Center During a Pandemic

Christine D. Esper MD, Laura Scorr, MD, MS, Sosi Papazian, MPH, Daniel Bartholomew, BS, Gregory J. Esper, MD, MBA, Stewart A. Factor, DO

Emory University, Department of Neurology, Atlanta, Georgia, USA

Background: Telemedicine has rapidly gained momentum in movement disorders neurology during the COVID‐19 pandemic to preserve clinical care while mitigating in‐person visit risk and requires ongoing study. Our objective is to present data that resulted from the rapid implementation of virtual visits in a large, academic, movement disorders practice during the COVID‐19 pandemic.

Methods: We describe the strategic shift to virtual visits over a 5‐week period and retrospectively examine elements that impacted the ability to switch to telemedicine visits using historical pre‐pandemic in‐ person data as a comparator, including demographics, distance driven, and diagnosis distribution with an additional focus on patients with deep brain stimulators.

Results: 686 telemedicine visits were performed over a five‐week period (60% of those previously scheduled for in‐office visits). Average age was 65 years, 45% were female, and 73% were Caucasian. Men were more likely to make the transition (p = 0.02). Telemedicine patients lived further from clinic compared to those seen in‐person (41.3 miles vs. 26.2 miles, p < 0.001); age was not a factor in making the switch; patient satisfaction did not change. There was a significant shift in the distribution of movement disorder diagnoses seen by telemedicine compared to pre‐pandemic in‐person visits (p < 0.001). Patients with deep brain stimulators were more likely to use telemedicine (11.5% vs. 7%, p < 0.001).

Discussion: Telemedicine is feasible, viable and relevant in the care of movement disorder patients, though health care disparities appear evident for women and minorities. Patients with deep brain stimulators preferred telemedicine in our study. Further study is warranted to explore these findings.

Presenting Author e‐mail: cedoss@emory.edu

15. Evaluating Patients’ and Neonatologists’ Satisfaction with the Use of Telemedicine for Prenatal Consultations in the Context of the COVID‐19 Pandemic

Maria Lapadula, MD, Shanna Rolfs, Edgardo Szyld, MD, MSc, Gene Hallford PhD, Tracie Anderson, MS, Mike McCoy, CRNP, Abhishek Makkar, MD

Division of Newborn Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center; Oklahoma City, Oklahoma, USA and OU College of Medicine, Oklahoma City, Oklahoma, USA

Background: The ongoing worldwide COVID‐19 pandemic places us in a challenging situation, with patients and caregivers being at higher risk of infection. Telemedicine is being extensively used across different specialties to provide medical consultations in an effort to minimize the viral spread and optimize the use of PPE. On these bases, the Section of Neonatal and Perinatal Medicine at The Children’s Hospital Oklahoma City, introduced virtual prenatal consultations between pregnant women with known fetal anomaly and neonatologists. Although the quality of healthcare delivered via telemedicine has shown to be non‐inferior to care given via traditional in‐person visits; satisfaction hasn’t been studied in these particular circumstances where physicians have the challenging task of communicating expected hospital course and prognosis related to fetal anomaly. The objective of our study is to evaluate patients’ and neonatologists’ satisfaction with the use of telemedicine for prenatal consultations.

Methods: This is a before‐and‐after designed study. We compared satisfaction levels of patients receiving video prenatal consultations via Zoom Pro™ with those receiving traditional in‐person visits. Anonymous and voluntary 5‐point Likert scale surveys were used to address 3 main components of satisfaction: the perceived quality of care, the professional aspects of the consultation, and the physician’s’ interpersonal skills. During the first stage of the study (from May 1, 2020 to June 30, 2020), we provided the satisfaction survey to patients receiving teleconsultations. In second stage (from July 1, 2020 to August 31, 2020), we will deliver the questionnaire to users receiving conventional in‐person consultations, as COVID‐19 restrictions are released. Concurrently, all neonatologists’ delivering virtual prenatal consultations received an anonymous and voluntary survey designed to evaluate professional’s satisfaction.

Results: Of the 21 telemedicine patients who participated, 85% were using video‐consultations for the first time. 85% found it easy to communicate with the neonatologist through telemedicine and all of them perceived they had the opportunity to ask questions. 85% understood the diagnosis and what to expect once the baby arrived. 85% perceived the overall quality of the consult as excellent, 10% as good, and only 5% (N = 1) as very poor (audio didn’t work properly). 100% felt privacy and confidentiality was protected and that the professional was polite and caring. 90% were very satisfied with the overall feeling of the teleconsultations. Although none of them felt unsatisfied, 2 did not answer that question. Analysis of physicians’ satisfaction surveys and control surveys assessing conventional in‐person consultations are pending at this time.

Discussion: Telemedicine was an efficient way to provide prenatal consultations for pregnant women with known fetal anomalies during the pandemic. Patients demonstrated a high degree of satisfaction after the visit. We expect to evaluate and report physicians’ satisfaction with teleconsultation in the near future.

Presenting Author e‐mail: Maria‐lapadula@ouhsc.edu

16. Telehealth Barriers to Care amongst a Complex, Geriatric Population

Monica Gillie, BSc¹, Diab Ali, BSc¹, Kathy Jo Carstarphen, MD, MPH²

¹University of Queensland Ochsner Clinical School, New Orleans, Louisiana, USA and ²Ochsner Clinic Foundation, New Orleans, Louisiana, USA

Background: The MedVantage Clinic, serving complex, geriatric population in New Orleans, Louisiana, began dedicated telemedicine training outreach in March 2020, during the COVID‐19 pandemic. Toward the goal of all patients having access to virtual visits, a team of 13 medical students accrued a total of 358.5 hours toward patient outreach. An average of 4.78 hours was spent per patient over the phone in telemedicine training.

Methods: MedVantage clinical data was analyzed to determine virtual visit success rates and patient barriers to virtual visits using current model of telehealth. Outreach data was collected per medical students including number of outreach attempts, hours spent training, and socioeconomic barriers to accessing virtual visits.

Results: At the end of the training period, only 18.8% of the 309 targeted MedVantage patients were able to connect to a virtual visit with a provider. While 86 patients were successfully trained, one third of these patients had difficulty with executing the technical demand of the virtual visit check‐in process. For the remaining patients, the main patient barriers identified were access to a smartphone or tablet, inadequate internet access, inaptitude in operating a smart device with limited social support, and inability to retrieve login credentials.

Discussion: There is a significant time burden spent on telemedicine training with currently poor success rates attributed to the socioeconomic barriers in our patient population. While it is invaluable for this high‐ risk, geriatric population to have access to virtual visit capabilities, it is not equitable within the current system that favors patients with access to smart devices and a social support, and disadvantages vulnerable populations.

Presenting Author e‐mail: V‐mgillie@ochsner.org

17. A Telehealth Literacy Screening Tool for Healthcare and Research

Diab Ali, BSc¹, Monica Gillie, BSc¹, Kathy Jo Carstarphen, MD, MPH²

¹University of Queensland Ochsner Clinical School, New Orleans, Louisiana USA and ²Ochsner Clinic Foundation, New Orleans, Louisiana, USA

Background: The benefits of telehealth from a social, financial, and practical sense are well established. However, there are many gaps in the literature regarding telemedicine services in geriatric and vulnerable populations. There is currently no telehealth literacy screening tool designed for use in care or research regarding patients with barriers to telehealth use. Related screening tools for technological, digital, and e‐health literacy are largely burdensome and exhausting for these complex patients. Further, success rates of telehealth are variable in these populations and there is no uniform understanding of the factors affecting use or how to increase engagement.

Methods: To gain insight from strengths and weaknesses of existing models, we prepared a narrative review using literature searches in English pertaining to technological, digital, e‐health, telehealth, and telemedicine literacy screening methods found using PubMed, Google Scholar, and Medline from January 2000 through May 2020.

Results: Here we propose a novel telehealth literacy screening tool (TLST) for concise, low‐burden screening of patient telehealth competency and comfort, based on an existing telehealth model.

Discussion: The TLST is designed to be a key instrument in identifying patients who need additional interventions to successfully connect with telehealth. Development of a TLST may thereby inform development of solutions in reducing barriers encountered in current telehealth.

Presenting Author e‐mail: v‐dali@ochsner.org

19. Virtual vs Traditional Care Settings for Low‐Acuity Urgent Conditions: An Economic Analysis of Cost and Utilization Using Claims Data

Tim Lovell, MBA, Jordan Albritton, PhD, MPH, Joe Dalto, PhD, Cheryl Ledward, MBA, Will Daines, MD

Intermountain Healthcare, Salt Lake City, Utah, USA

Background: On‐demand, direct‐to‐consumer video (or virtual) visits represent one of the fastest growing telemedicine services. Due to the absence of an in‐person physical examination, some question the effectiveness, efficiency and value of virtual care visits. To address these questions, we conducted a retrospective, cross‐sectional review of Intermountain Healthcare’s virtual care program.

Methods: This study used SelectHealth claims for virtual, urgent, primary and emergency care delivered between April 1, 2016 and March 31, 2017. We included all claims with primary diagnosis from the 9 most common categories for virtual care. A secondary data source included survey data indicating how virtual visits redirect care.

Results: We matched 1,531 virtual visit claims with claims from urgent (4,377), primary (4,388) and emergency care (2,285). There were no differences in follow‐up rates between virtual and urgent care and no differences in antibiotic use between virtual and urgent or primary care. Virtual care was significantly lower than all other care settings in utilization of laboratory and imaging services, index visit cost and total costs over 21 days.

Discussion: This study affirmed lower cost for virtual care without an associated increase in overall follow‐up rates or antibiotic use when compared with urgent or primary care. This suggests that virtual visits are can be used to lower the total cost of care for applicable conditions. The implications are that virtual visits help lower operational costs of providing care, particularly in integrated systems with capitated reimbursement. Under the right circumstances, the increased adoption of virtual care should lead to greater savings

Presenting Author e‐mail: tim.g.lovell@gmail.com

20. Evaluation of a Telemedicine Program Managing High‐Risk Pregnant Women with Pre‐Existing Diabetes

Yi‐Shan Sung, PhD, Donglan Zhang, PhD, Hari Eswaran, PhD, Curtis Lowery, MD

University of Arkansas Medical Sciences, Little Rock, Arkansas, USA

Background: Since its inception in 2003, High Risk Pregnancy Program (formerly known as ANGELS: Antenatal & Neonatal Guidelines, Education and Learning System), a telemedicine program initiated by the University of Arkansas Medical Sciences (UAMS) and the Arkansas Department of Human Services, has transformed the landscape of obstetrical and neonatal care delivery in Arkansas. Up to now, there are 44 rural telemedicine sites in the network across Arkansas with over 2,500 obstetrical consults provided annually to high‐risk pregnant women. The study aimed to evaluate the effects of the telemedicine program on health outcomes, utilization of health services, and medical expenditures of pregnant women with pre‐existing diabetes and their newborns.

Methods: The study sample was selected from the Arkansas Medicaid claims data and was linked with infant birth and death certificates obtained from the Arkansas Department of Health and UAMS telemedicine records from January 2013 through December 2016. We used the propensity score matching approach based on participants’ characteristics to create three groups ‐ UAMS telemedicine care, UAMS in‐person care, and non‐UAMS prenatal care. We assessed maternal health care utilization such as inpatient care services, outpatient care services, medication use, and outcomes including caesarean section and severe maternal morbidity. We also assessed infant birth outcomes such as infant mortality and preterm birth. In addition, we compared the total health care expenditures for maternal and neonatal care.

Results: A total of 1609 pregnant women with pre‐existing diabetes and their newborns were selected, and 172 (10.69%) of them received UAMS telemedicine care. Pregnant women receiving UAMS telemedicine care had fewer number of inpatient admissions on average (1.18 vs 1.31; 95% Confidence Interval (CI): ‐0.27, 0.00), lower insulin usage rate (42% vs 60%; 95% CI: ‐29%, ‐7%) and lower medical expenditures for maternal care ($7,846 vs $10,644; 95% CI: ‐$4,089, ‐$1,507) compared with those receiving UAMS in‐person prenatal care. Pregnant women receiving UAMS telemedicine care had more prenatal care visits (10.45 vs 8.57; 95% CI: ‐2.96, ‐0.81) and higher insulin usage rate (42% vs 27%: 95% CI: 5%, 26%) but similar medical expenditures for maternal care ($7,846 vs $7,051), compared with patients only receiving non‐UAMS in‐person services. Infants born to mothers who received UAMS telemedicine care had a lower percentage of APGAR score < 7 (6% vs 14%, 95% CI: ‐14%, ‐1%) but a higher percentage of birth weight above 4000 grams (12% vs 6%, 95% CI: 0%, 12%), compared to infants born to mothers receiving UAMS in‐person prenatal care. Caesarean section, severe maternal morbidity, and infant mortality rate were similar across the three groups.

Discussion: The UAMS ANGELS telemedicine program is associated with improved utilization of prenatal care and reduced inpatient admissions among high‐risk pregnant women with pre‐existing diabetes. Telemedicine services did not differ from usual in‐person services in outcomes, including severe maternal morbidity, infant mortality, and overall medical expenditures for maternal care.

Presenting Author e‐mail: ysung@uams.edu

21. Virtual Rounding for Displaced Medical Students During COVID‐19

Adam Zakaria BA, Smrithi Sukumar, BA, Nancy Choi, MD, Cindy J. Lai, MD

Division of Hospital Medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA

Background: Due to the COVID‐19 pandemic, third‐year medical students were temporarily not allowed on‐site for clinical clerkships, participating in virtual learning instead. Given that clerkships are designed to be an experiential learning opportunity with direct patient care and could not be fully replaced by online modules and didactics, we devised an innovative way to provide clerkship students with clinical exposure during their virtual learning period.

Methods: The Internal Medicine (IM) clerkship at UCSF created a Virtual Rounding curriculum to help clerkship students develop skills in inpatient pre‐rounding, oral presentation and clinical reasoning. In this three‐part curriculum, each student virtually followed the clinical course of one hospitalized patient per week, but did not participate in direct patient care. Each virtual team consisted of 3‐4 clerkship students and was led by volunteer tele‐instructors (one attending physician and two teaching assistants [TAs]– a resident physician and a fourth‐year medical student [MS4]). Virtual Rounds (VR) were held three times a week during a two‐week virtual learning period. On each day of VR, students first “pre‐rounded” on their assigned hospitalized patient by gathering pertinent data from the electronic health record, and preparing an oral presentation. Students then called into hospital rounds to listen to the wards team’s patient presentation. Lastly, students met with their VR team in a one‐hour session held by videoconferencing (Zoom), where each student delivered an oral presentation on their patient. The tele‐instructors provided strategies for pre‐rounding, feedback on oral presentations, and clinical teaching.

Results: Sixteen clerkship students and 21 volunteer tele‐instructors (12 TAs, 9 attendings) participated in the first two blocks of VR. Students and tele‐instructors completed anonymous, post‐curriculum surveys with Likert‐scaled and open‐ended questions. Student response rate was 56% (9/16). After VR, a majority of students felt that they improved in their pre‐rounding abilities (89%), clinical reasoning skills (78%), and oral presentation abilities (100%). Although some students experienced challenges coordinating calls with wards team members on rounds, all students reported that virtually following a hospitalized patient enabled better learning compared to completing prepared online cases, with one student stating that “it was nice to see patients improve and problem solve in real time.” Tele‐instructor response rate was 67% (14/21). Fifty‐seven percent felt that VR enabled a more favorable teaching environment for students compared to hospital rounds. Instructors appreciated that the VR format facilitated teaching on oral presentations skills and provided dedicated teaching time for medical students without competing responsibilities of patient care or resident education.

Discussion: Based on initial feedback, our VR curriculum can be an effective tool for providing clerkship students with clinical experiences during the COVID‐19 pandemic. Not only did all of the student’s self‐report VR to be a positive learning experience, but all of the tele‐instructors also claimed to benefit from the experience. Without any direct patient care or resident teaching responsibilities, VR allowed the tele‐ attending and teaching assistants to solely focus on third year medical student skill development around acquisition and interpretation of clinical information. VR offered third year medical students a unique and valuable exercise in clinical data synthesis and reasoning during a time when learning through direct patient care was not possible, and may continue to supplement in‐person medical education opportunities once in‐person clerkships resume.

Presenting Author e‐mail: Adam.Zakaria@ucsf.edu

22. Impact of Teledermatology Program on Dermatology Resident Education: A Mixed Methods Analysis

Adam Zakaria BA¹, Toby Maurer, MD², Erin Amerson, MD³

¹University of California, San Francisco School of Medicine, San Francisco, California, USA;

²Department of Dermatology, Indiana University, Indianapolis, Indiana, USA; and ³Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA

Background: Teledermatology (TD) enables dermatologists to remotely evaluate and triage patients, and has become widely applied in various healthcare settings. Despite many dermatology residency programs incorporating TD into their curriculums, few studies have analyzed its impact on resident experience and education. In order to address this gap, we sought to collect and evaluate dermatology resident perspectives on the TD program at the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). We also sought to determine whether time was spent more efficiently during TD learning compared with clinic learning.

Methods: During a dedicated weekly session that averaged 100 minutes, a team of 3‐4 dermatology residents at different levels of training and an attending dermatologist met to review an average of 70 TD cases referred to the ZSFG dermatology department. Cases were first reviewed by a resident and then presented to the attending who helped finalize the assessment and plan in the TD platform. If a particularly complex or interesting case was being reviewed, all participating residents were made aware and joined the discussion. Current dermatology residents and recent graduates who participated in the TD program were asked to provide narrative comments about their experiences with the TD sessions. These responses were coded emergently and evaluated through inductive thematic analysis with focus on manifest content. To assess the effects of TD on the number of cases evaluated, we compared a productivity index of number of cases managed per resident per hour between in‐person dermatology clinic and the TD sessions during our study period from June 2017 to December 2017.

Results: Fifteen out of 21 (71%) potential respondents completed the survey. The narrative comments were positive in all fifteen cases and coding unearthed four primary content areas. Comments about TD facilitating review of a high volume of cases appeared in nine out of fifteen narratives. Another content area that appeared in eight out of fifteen narratives was TD providing a low‐stress learning environment. Two respondents even used the word “fun” to describe their TD experiences. A related idea that appeared in 8 out of 15 narratives centered on TD providing opportunities to consider a wider range of differential diagnoses. Comments about TD improving visual skills appeared in 8 out of 15 comments, with one respondent writing that TD “obviates any awkwardness when discussing lesions in front of a patient and allows residents to ask detailed questions about morphology.” Residents averaged 149.7 hours per month evaluating 680.7 patients in dermatology clinic with a productivity ratio of 4.55 (680.7/149.7) and averaged 26.1 hours per month reviewing 299.7 referrals in TD sessions with a productivity ratio of 11.49 (299.7/26.1). These differences were statistically significant with a p‐value less than 0.01.

Discussion: We qualitatively and quantitatively analyzed the impact of integrating the teledermatology triage system at ZSFG into the UCSF dermatology residency curriculum. Our qualitative findings demonstrate that teledermatology has been well‐received by dermatology residents and helped pinpoint the aspects of teledermatology that are most educationally salient from the resident perspective, which is an important first step towards establishing guidelines for teledermatology‐based education best practices. Our quantitative analysis found that teledermatology enabled residents to evaluate more than double the amount of patient cases per unit time as compared to working in clinic. Therefore, our study findings suggest that teledermatology can be an effective tool for dermatology resident education.

Presenting Author e‐mail: Adam.Zakaria@ucsf.edu

23. Diagnostic Breakdown and Healthcare Utilization among Patients Triaged through Teledermatology at a Large, Safety‐Net Hospital

Adam Zakaria BA¹, Toby Maurer, MD², Kieron S Leslie, MD³, Erin Amerson, MD³

¹University of California, San Francisco School of Medicine, San Francisco, California, USA;

²Department of Dermatology, Indiana University, Indianapolis, Indiana, USA; and ³Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA

Background: Teledermatology (TD) enables remote evaluation and triage of dermatology patients. While studies have found TD to increase patient access, generate cost savings and be well‐liked by patients and providers, a common concern surrounding TD implementation is that it may be compromising the quality of care delivered to patients. Some studies have claimed adequate quality of care by comparing diagnostic concordance between in‐person visits and TD consultations, and a few studies have evaluated clinical outcomes between patients receiving care through in‐person visits and TD. Another way to approach the assessment of quality of care is by assessing the clinical courses of patients triaged. However, only one small‐scale study has conducted such analysis. To address this gap, we analyzed the TD triage system at the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), which is a large safety‐net hospital paid primarily through managed care agreements.

Methods: The ZSFG store‐and‐forward TD program was introduced in January 2015 as a triage system for all dermatology referrals and our retrospective, descriptive analysis captured all adult patients who received consultations between June and December 2017. One way to gauge the appropriateness of triaging decisions is by analyzing healthcare utilization with the hypothesis that patients triaged to dermatology clinic would require more doctor visits. For patients triaged to their primary care physician (PCP), we collected data on the number of PCP visits within 6 months of their TD consultation. PCP visits were only included if the patient’s dermatologic disease was included in the associated visit’s note. For patients triaged to dermatology clinic, we collected data on the number of dermatology clinic appointments each had within 6 months of their TD consultation. To control for differences in diagnostic categories seen in each setting, we also compared the average number of dermatologic disease‐related visits within 6 months of the TD consultation for diagnoses that made up at least 1% of the total diagnostic abundance and for which at least 25% of patients are triaged to each of the settings.

Results: The analysis captured 2,098 patients from the San Francisco Health Network system. Among the patients triaged to a PCP visit with TD recommendations, patients averaged 0.45 [95% CI 0.40, 0.50] dermatology‐related office visits within 6 months of their TD consultation. Among the patients triaged to a dermatology clinic visit, patients averaged 1.24 [95% CI 1.15, 1.32] dermatology‐related office visits within 6 months of their TD consultation. A statistically significant difference exists between these values with a p‐value < 0.001. After stratifying based on diagnostic categories, a statistically significant difference in healthcare utilization between patients triaged to a PCP visit versus a dermatology visit persisted among patients with seborrheic keratosis, benign nevus, psoriasis, atopic dermatitis, seborrheic dermatitis, acne, lichen simplex chronicus, tinea infection, skin tag, rosacea, onychomycosis, xerosis, vitiligo, stasis dermatitis and androgenetic alopecia. A non‐statistically significant difference was found in patients with cyst, verruca vulgaris, and scabies.

Discussion: In line with our initial hypothesis, our analysis found that patients triaged to dermatology clinic demonstrated increased healthcare utilization as compared to patients triaged to a PCP visit with TD recommendations. When patients were stratified based on their dermatologic diagnosis, the increased healthcare utilization among patients triaged to dermatology clinic persisted in the majority of diagnostic groups. These results suggest that the TD system correctly triaged patients to the appropriate setting because patients with more severe disease received more care pertaining to their dermatologic disease. Therefore, TD has the potential to provide timely and quality care to dermatology patents.

Presenting Author e‐mail: Adam.Zakaria@ucsf.edu

24. The Leap to Virtual Care: Rapid Implementation and Evaluation of Telehealth Training Post COVID‐19 in a Large Urban Subspecialty Health Centre in Canada

Joelle Pellegrin RN, BSN, BEd, BA, Melissa Coop, MN, RN, CpedN (C), Rita Janke, RN MSN, Kasra Hassani, PhD MPH, Theresa McElroy, PhD, MIH, BScOT, Linda Wu, BSc, MHA, PMR, Kit Johnson, MBA MSc (Pharm)

Child Health BC, Provincial Health Services Authority, Vancouver, British Columbia, Canada

Background: In March 2020, in response to the COVID‐19 pandemic and the public health officer’s call for British Columbians to stay at home, measures were introduced that resulted in the closure of non‐urgent hospital visits, including British Columbia’s Children and Women’s hospital (C&W). To allow for continuity of care, a rapid transition to telehealth was necessitated. Given the low levels of baseline exposure to telehealth, training and support was required to assist with this transition. Child Health BC (CHBC) was tasked with developing resources and providing training to C&W clinicians and support staff.

Methods: Training content included basics of telehealth, clinical requirements for conducting a telehealth visit, and basics of how to schedule and operate two telehealth platforms: Zoom and Skype for Business. All training was provided through 90‐minute webinars and used a train‐the‐trainer model whereby CHBC staff were trained to deliver the sessions to C&W clinicians and support staff. Trainings were provided several times a day for a period of 6 weeks. Each session included a lead trainer and technical support trainer and a scheduled on‐call trainer who would step in to support the session if there were technical difficulties or a sudden change in the schedule of one of the trainers. The quality of training was monitored using a brief post‐training survey and via feedback collected throughout the sessions. The training team met daily to discuss progress, logistics, and to incorporate the recently collected feedback into the training module. Training was advertised to staff by emails sent from C&W leadership. The training program was evaluated through a follow‐up survey sent to all participants after the training program ended.

Results: Ten trainers trained 895 staff through 101 sessions. The evaluation survey response rate was 39%. The survey participants overall found the training helpful in their transition to telehealth. On average, self‐ reported knowledge and confidence increased by 58% and 61% respectively. This increase was more pronounced in participants with lesser prior exposure to telehealth. The majority (75%) of participants had limited to no prior exposure to telehealth, yet 66% of all participants had used telehealth (scheduled sessions or conducted visits) since the training and 87% indicated an intent to use telehealth in the future. Effectiveness of the platforms, well‐functioning devices, and buy‐in from patients and families were the top reasons why participants found their telehealth sessions successful. Meanwhile, technology and connection problems were listed as the main challenges. For future trainings, participants suggested trainings tailored by subject (e.g. a specific platform, functionality, and tailored to purpose of use), identified super‐users at each C&W clinic, and self‐ paced modules as preferred modalities. In response to the feedback, self‐paced webinar recordings were created for future training.

Discussion: Overall, the team was successful in training over 71% of the intended C&W clinicians and support staff in need of training in a short period of time and assist in C&W’s transition to telehealth. The incorporation of evaluation into the training program allowed for rapid improvement and recommendations for improving training and addressing barriers moving forward. The COVID‐19 pandemic has led to a rapid move to telehealth, bringing with itself many advantages including safety and ease of access for patients, and lower cost to the health care system. However, this transition needs to be maintained and improved by leadership and technical support. Such support could include development of core competencies in telehealth training of new staff and ongoing training and refreshers for current staff, further education and support for patients and families, especially those with complex needs, and finally improvements on the technology and connection platforms.

Presenting Author e‐mail: Joelle.Pellegrin@phsa.ca

26. Bedside Telemedicine During a Pandemic: A Community Collaboration

Kristin Carlton, RN, MSN

Children’s Hospital, Houston, Texas, USA

Background: As the Novel Covid‐19 virus exploded into Texas in March of 2020, Children’s Health System of Texas (CHST) proactively decided to prevent the spread of the disease by using telemedicine within the hospital walls. Confronted with limited resources to cover bedside telemedicine across the hospital, and schools closed via government mandate, the opportunity arose to leverage now‐sitting school‐ based telemedicine equipment for much‐needed patient care with bedside telemedicine. School districts, particularly school nurses, were eager to support the endeavor. In turn, Children’s Health Clinical Administration was eager to adopt the technology to educate the clinical staff for bedside use. Using Virtual education Nurses, Providers, and all ancillary support services were trained on the Bedside Telemedicine Process. The first unit to GO‐LIVE at CHST was the designated SIU (Sick Isolation Unit) housing potential positive and confirmed COVID positive patients.

Methods: As school districts closed, the Children’s Health School Telehealth IT team was instrumental to collect 68 School Telehealth carts in 8 School Districts. The team retrieved the carts from schools, sterilized the units and redeployed them across 12 service lines spanning 2 Children’s Health Hospital campuses. The SIU was designated on the Dallas Campus for potential positive and confirmed Covid‐ 19 positive patients. The Virtual Heath IT Team worked with the TeleSpecialty team, Nursing Administration, and the CRT (Clinical Resource Team). Parallel to standing up bedside nursing, Medical Providers and ancillary support services were trained to conduct bedside visits on inpatients. The virtual education platform used to train school nurses for school‐based telemedicine was replicated for bedside nurses. A separate training program was developed for Physicians. Education, competency checks, and utilization measurements were rapidly developed and deployed over a 3‐week period, and the efficacy of the Telehealth program was reported to the Incident Command Center.

Results: In a matter of weeks, we were able to convert hospital‐wide practice adopting the use of technology without impacting the delivery of care to our pediatric patients. The telemedicine process allows providers to continue providing care while decreasing exposure time and reducing PPE utilization.

• • 12 Service lines – including 350 Providers

• • 13 Floors/Units – including 899 Nurses trained

• • 1,160 Bedside Telemedicine encounters

Discussion: Implementing telemedicine at Children’s Health System of Texas has been a goal since 2014. Commencement of the program started with schools and exists within 185 schools in 26 districts. Expansion of telemedicine services and adoption by staff has occurred inside the hospital walls and across a plethora of clinical settings. As the pandemic numbers increase in Dallas County, and throughout the State of Texas, the ultimate preparedness of decreasing exposure to staff, savings of PPE and ultimately saving lives continues to remain the key to success of using telemedicine. In addition, the proven success of inpatient telemedicine use demonstrates the need and power of technology at the bedside. Moving forward, a TeleNursing Steering committee will meet monthly to discuss continued staff adoption, policy and procedure development along with innovation and process improvement. Children’s Health continues take pride in the innovative delivery of care to align with their Mission to make lives.

Presenting Author e‐mail: kristin.carlton@childrens.com

27. Connecting Pediatric Psychologists with Educators: Adapting an ECHO Series during COVID‐19

Skylar Bellinger, PhD, Leni Swails, PhD, Alice Zhang, PhD, Stephanie Punt, MA, Ilana Engel, BA, Annaleis Giovanetti, BA, Anna Nicole Aniel, MA, Katy Tepper, PhD, Michele Utt, MA, Robert Stiles, MPH, MA, Eve‐Lynn Nelson, PhD, FATA

Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas, USA

Background: The Project ECHO community has rapidly responded to the pandemic. Virtual schooling adopted during the pandemic creates an opportunity for greater home‐school collaboration, but teachers may not have prior training in implementing virtual academic and behavioral services. Prior to COVID‐19, an ongoing ECHO series (“Function Fridays” based on functional behavior analysis) was established to support educators in creating trauma‐informed, behavioral interventions. This case study highlights the role of an ECHO series connecting pediatric psychologists with educators to address challenging behaviors in school, and modifications made to an ongoing ECHO series during COVID‐19. We present a case summary of an educator who participated in Function Fridays and the intervention originally created for a child attending an in‐person school, and how behavioral intervention was adapted to be implemented virtually, with the collaboration of school staff and the student’s family.

Methods: Participants recruited for this ECHO agreed to attend all sessions and to identify one student or child to practice and apply skills learned throughout the series. The eight sessions were designed to feature topics including behavioral data collection, overview of functions of challenging behaviors, functional behavior assessment (FBA)‐antecedents, FBA‐consequences, Prevention, Intervention (two sessions), and crisis planning. The series took place twice a month over a 4‐month period between early January and end of April of 2020. These one‐hour ECHO sessions included a 5‐10‐minute introduction and check‐in, a short 15‐minute didactic presentation related to prevention, assessment, and treatment of challenging behaviors followed by 35‐40 minutes of presenting and discussion of one case from the community participants. After the fifth ECHO session, schools were closed statewide for the remainder of the academic year. The ECHO planning team quickly convened to discuss next steps, and how to best support students, educators, and families.

Results: The following case for discussion in the Function Fridays ECHO. The team identified the behavior, collected data on the frequency, antecedents, and consequences of behavior, identified a hypothesized function of the behavior, and created a function‐based behavior intervention plan. The student was a kindergartener diagnosed with Disruptive Mood Dysregulation Disorder without history of attending early childhood services. The student’s teacher had concerns about significant disruptive behavior/work refusal, exemplified by the student throwing items on the floor and crawling under desks. The student averaged 4, 15‐minute episodes at least 4 days/week, and an average of 4 office referrals/week. Prior to COVID‐19, the school counselor and teacher were able to identify the function of shutdown behavior as access to adult attention and to decrease this behavior through a behavioral plan providing adult attention for appropriate behaviors. During COVID‐19 the student’s mother continued charting the student’s daily behaviors on the refrigerator. Mom reported generalizing the intervention system principles for use during other home routines. The student’s mother reported significant improvement in the child’s behavior.

Discussion: Unexpectedly, ECHO’s virtual meeting and case consultation format provided an effective mechanism for supporting school and community providers during the pandemic. Participating educators used the virtual school “opportunity” to implement innovative behavioral interventions and enhance school‐home collaboration and improve outcomes for children with challenging behaviors. Functional behavior interventions can be modified to implement virtually/ during pandemic. This highlighted a unique example of how a virtual, home‐based behavior intervention plan can improve child behavior, enhance family‐school collaboration and promote consistency across settings.

Presenting Author e‐mail: sewpunt@ku.edu

28. Fostering a Culture of Resilience: A Videoconferencing Series to Support Healthcare Workers during the COVID‐19 Pandemic

Stephanie Punt MA, Annaleis Giovanetti, BA, Ilana Engel, BA, Alice Zhang, PhD, Moira Mulhern, PhD, Janet Richardson‐Barce, MPH, MBA, Jodi Schmidt, MBA, Robert Moser, MD, Ronald Robinson, MD, MPH, MBA, Eve‐Lynn Nelson, PhD, FATA

University of Kansas Medical Center, Kansas City, Kansas, USA

Background: Public health crises, such as pandemics, are often accompanied by uncertainty and distress. Subsequently, with isolation and stay‐at‐home orders adopted across states, rural health workers experience additional financial and personal stressors related to medical clinics closing or reducing hours. Early on in the pandemic, health workers within our system wide collaborative, serving rural medical clinics across the Midwest, indicated increased distress. Resilience research suggests that when leaders of a group are distressed, individuals within that group also experience distress. As part of a Quality Improvement project, we designed a videoconferencing intervention to support our health workers serving rural communities during the pandemic.

Methods: A 6‐month videoconferencing series was developed to support health workers. Adapted from the10 Facets of Highly Resilient People, an evidence‐based protocol based on the resilience model, this series was distributed to 350 health workers and was delivered once/month to at least 160 health workers within our collaborative. Each “huddle” provided participants with psychoeducation and taught practical skills related to: Self‐Calming, Self‐Care, Ability to Self‐Replenish, Emotional Expressiveness, Non‐Judgement, Self‐Supporting, Hope and Optimism, Hardiness, Sense of Coherence, and Social Support. Participants were encouraged to practice these skills individually and to implement these skills within health teams. Participants also opted in to self‐report mood (GAD‐7, PHQ‐2), Resilience (UW Resilience Scale), quality of life (ProQOL), work experiences, and ways to improve upon the current series via an anonymous survey.

Results: A total of 25 participants opted in to fill out self‐report measures. Respondents were on average 48.8 years old, the majority identified as women (82%), and all reported being employed in leadership or team lead positions within the collaborative. Respondents reported no concerns related to professional quality of life and rated themselves as having (M, SD) average compassion satisfaction (T = 40.8,7.2)), average burnout (T = 21.7, 6.0), and average secondary trauma (T = 20.9, 3.8). Respondents reported average levels of resilience (T = 55.1, 6.8) and described experiencing depressive and anxious symptoms consistent with the additional stressors associated with the pandemic. The majority of respondents also rated good job satisfaction, having a positive relationship with co‐workers and leadership, and sharing similar values with leadership. Respondents did indicate difficulty with feeling stressed or tense at work and managing work‐life balance. Additionally, respondents suggested that future iterations of the series are recorded, that opportunities for individualized resilience coaching be available, and coaching specific to tough leadership situations be provided.

Discussion: Through this 6‐month evidence‐based videoconferencing series we focused on fostering a resilient culture within our health workers and health teams. While a subset of participants indicated that they do already have resilience skills, our goal was to bolster skills innate to some individuals and allow the opportunity for individuals to learn and practice additional resilience skills. In developing this videoconferencing series to support our health workers across the rural Midwest, we have been able to better understand how the COVID‐19 pandemic is impacting our health care teams and thus patients across the rural Midwest. Through utilizing technology to deliver distance learning education to our health workers, we were also able to model and improve familiarity of videoconferencing technology with our health workers. This improved familiarity, in turn, helped refer patients to telehealth services. Findings will be shared through the Heartland Resource Center for regional distribution.

Presenting Author e‐mail: sewpunt@ku.edu

30. Development of an Intercampus Outpatient Virtual Care Experience Survey

Shabnam Ziabakhsh, PhD, CE¹, Susan Schroeder, MBA1, Karen Epp¹, Sharlynne Burke‐ RPN, BA, MSW¹, Edwina Houlihan‐ RN, BScN, MBA², Tamara Crozier, MSc, BA, BSN, RN³, Melanie Rathgeber, MA, MCC⁴, Jenny Morgan, EdD², Sophy Davis, MPH¹

¹BC Children’s Hospital, Vancouver, British Columbia, Canada; ²BC Women’s Hospital + Health Centre, British Columbia, Canada; ³Provincial Health Services Authority, British Columbia, Canada; and ⁴Child, Youth and Reproductive Mental Health Programs, British Columbia, Canada

Background: During the COVID‐19 pandemic, BC Women’s Hospital + Health Centre and BC Children’s Hospital began to deliver care virtually to their outpatient populations through one‐on‐one consultations and group‐visits, using Skype and Zoom as platforms. In order to assess the appropriateness, acceptability and patient’s overall experience with virtual care an intercampus survey was developed with engagement from key stakeholders. The goal was to develop an experience survey tool that can be used across both adult and pediatric subspecialty service delivery. The process of development of this tool will be described in this presentation.

Methods: Following a literature review twenty survey tools were identified that captured virtual care experiences. Subsequently an inventory of questions was formed based on experience quality dimensions of access, acceptability, convenience, usability, tech support, confidentiality/security, communication/information, patient‐provider rapport, cultural safety/respect, outcome/usefulness and overall satisfaction. Patients and health managers reviewed each question and voted on its inclusion/exclusion via a modified Delphi process. The goal was to select relevant questions that could be applied across wide service areas and populations.

Results: The selected questions were pretested with patient groups in an iterative fashion for face validity and comprehension. Through this process questions were refined, reworded, combined, deleted and added. The survey will be launched at clinics and its psychometric properties (factor structure and internal consistency) will be tested.

Discussion: The method for designing the virtual care survey (as described in this presentation) can serve as a guide to support the development of other patient‐reported experience measures. Capturing patient’s voice is an integral part of patient‐centered service and care planning, and an important required component of Accreditation Canada. Continuous monitoring of patient experiences using self‐reported tools, combined with feedback mechanisms to managers and healthcare providers, can lead to service improvements and a culture of quality and patient engagement.

Presenting Author e‐mail: sziabakhsh@cw.bc.ca

31. Site Coordinators’ Perspectives on Implementation of School‐Based Telebehavioral Health Services

Annaleis Giovanetti BA, Ilana Engel, BA, Anna Nicole Aniel, MA, Stephanie Punt, MA, Alice Zhang, PhD, Skylar Bellinger, PhD, Michele Utt, MA, Robert Stiles, MPH, MA, Eve‐Lynn Nelson, PhD, FATA

University of Kansas Medical Center, Kansas City, Kansas

Background: Despite the rapid growth of telehealth services offered across settings, the implementation of school‐based telebehavioral health services has been relatively slow. There are a number of advantages to support the use of these services and to increase access to evidence‐based care for youth. The school provides a familiar and convenient environment for families, helps reduce missed class for children, and facilitates effective communication between parents, teachers, and providers. For these programs to be successfully implemented, it is essential to engage all stakeholders in the process, including school nurses, telehealth site coordinators, or other telehealth staff. The current quality improvement project aimed to interview site coordinators involved with school‐based telebehavioral health services across Kansas to improve and streamline implementation. Our goal was to examine barriers and successes of implementation and the components necessary for sustainability of these services.

Methods: As a part of a quality improvement project, we contacted site coordinators involved in the implementation of school‐based telebehavioral health services across Kansas. Six participants participated in semi‐structured qualitative interviews about their experiences with telebehavioral health. Interviews were transcribed and thematic analysis was utilized to extract themes across interviews, and themes were cross‐checked by multiple researchers. Participants also completed a quantitative survey evaluating organizational readiness for change (ORIC), which captures their shared resolve to implement telebehavioral health services and beliefs about whether the organization is capable of implementing these services.

Results: Preliminary themes from interviews with site coordinators (n = 6, median age = 42.5 years, 100% female) highlight increased access to care, reduced travel time, and the unique role of the site coordinator in telebehavioral health with youth. Participants underscored the benefits of implementing strategies both at home and school by involving parents, teachers, and other school staff in child’s care. Site coordinators reported being uniquely situated to build trust with families, offer local resources to support family members and advocate for students’ and families’ needs. Site coordinators noted difficulties with communication, paperwork, scheduling, finding appropriate space, and transitions between providers. Most site coordinators were very satisfied with their communication with the telemedicine hub site regarding technological concerns. Site coordinators also discussed the need for more awareness of telehealth offerings in the community. Site coordinators endorsed commitment within their workplace to implement telebehavioral health (83.3% Agree, 16.7% Somewhat Agree), but more uncertainty about being confident that the momentum for services is sustainable (33% Agree, 50% Somewhat Agree, 16.7% Neither Agree nor Disagree).

Discussion: Site coordinators’ insights can provide valuable guidance to existing school‐based telebehavioral health programs and sites considering implementing evidence‐based services. The emphasis site coordinators place on relationships, communication, continuity, and advocacy for families and students underscores how essential coordinators are for providing high quality telehealth services in schools. Overall, coordinators reported motivation to implement telebehavioral health and positive beliefs that their workplace can effectively implement these services. However, site coordinators’ focus on the need for champions and increased awareness of telehealth services in their communities highlights a need for outreach efforts beyond the site itself. The perspective of these stakeholders is essential for ensuring the continued successful implementation and sustainability of these services. Lessons learned will also be shared with the Heartland Telehealth Resource Center for regional dissemination.

Presenting Author e‐mail: annaleis@ku.edu

32. Hospice Team Members’ Perceptions of Telehealth Adoption in Rural and Frontier Communities

Ilana Engel BA¹, Annaleis Giovanetti, BA¹, Anna Nicole Aniel, MA¹ Stephanie Punt, MA¹, Gary Doolittle, MD¹, Sandy Kuhlman, BSN², Joe Barnes, MD², Natasia Adams, PhD¹ Adam Lomenick, BS¹, Eve‐Lynn Nelson, PhD, FATA¹

¹University of Kansas Medical Center, Kansas City, Kansas, USA and ²Hospice Services and Palliative Care of Northwest Kansas, Inc., Kansas City, Kansas, USA

Background: Telehealth services have cost‐saving and travel time advantages for a variety of clinical needs in rural areas. Hospice care is an important area for the expansion of these services, and videoconferencing provides improved communication between staff, patients, and family. Understanding the use of telehealth in hospice care is essential to addressing barriers to care, including long distances. Hospice Services, Inc. (HSI) is a leader in rural hospice care serving 16 counties, over 15,000 square miles, and two time zones in northwestern Kansas. In partnership with University of Kansas Medical Center (KUMC), HSI introduced mobile tablets and videoconferencing to connect patients, family, providers, and staff. Since 2017, HSI has facilitated more than 250 TeleHospice encounters with over 900 attendees. The purpose of this project was to understand hospice team members’ experiences with telehealth, including successes and challenges, in order to advance the implementation of TeleHospice.

Methods: In 2019, semi‐structured interviews with hospice staff were conducted for quality improvement (QI) purposes aimed at understanding the perceptions of hospice team members involved in adopting the use of videoconferencing in their work with patients, caregivers, and other team members. This project was approved as QI by the KUMC Institutional Review Board. HSI staff members involved in the implementation of TeleHospice were invited to participate by email. A total of thirteen qualitative interviews were completed. Interviews were transcribed and thematic analysis was utilized to extract themes across interviews. Themes were cross‐checked by multiple researchers. Quantitative information, such as years of experience in hospice care and length of time since first exposed to telemedicine, was also collected.

Results: Hospice team members (n = 13, mean age = 54.77) provided feedback regarding challenges and successes of TeleHospice, including comments on recently introduced iPad placements and electronic medical records. Preliminary findings highlight themes about the technology involved with these services and how it impacts quality of care. Over half of the team members (53.8%) did not have previous exposure to telemedicine prior to the implementation of TeleHospice. Preliminary analyses reveal that team members discussed technical aspects of interactive televideo equipment, as well as their use of these services to communicate with staff and providers. Additionally, team members provided insight regarding perceptions of how TeleHospice meets patients’ needs and their experiences with the services. Interviewees commented on future directions for TeleHospice and ideas for how to extend and improve hospice care using telehealth.

Discussion: Understanding how TeleHospice processes work in daily practice can help improve telehealth adoption and hospice care. These insights can inform current TeleHospice practice and advance hospice services in order to best meet patient and family needs. Lessons learned from the implementation of telehealth services were shared within the partnering organizations and these lessons can also be disseminated more widely to contribute to quality patient care beyond this partnership. This project was conducted prior to COVID‐19 and can offer insight to those hoping to implement evidence‐based components of TeleHospice given the current constraints on visitation.

Presenting Author e‐mail: ilana.j.engel@ku.edu

33. Ophthalmology Residents as In Situ Telemedicine Extenders in the Emergency Department during the COVID‐19 Surge

Jessica Fleischer‐Black MD¹, Jay Horton, MSN, MPH, PhD^1,2, Claire Ankuda, MD, MPH^1,2, Christopher Woodrell, MD^1,2, Emily Chai, MD^1,2, Harsha Reddy, MD³, Erick Eiting, MD, MPH¹, Yvette Calderon, MD¹

¹Department of Emergency Medicine, ²Departments of Palliative Care, and ³Ophthalmology Icahn School of Medicine at Mount Sinai, New York, New York, USA

Background: During the COVID‐19 surge in New York City, our hospital system put in place a 24‐hour helpline to connect Emergency Department (ED) physicians to Palliative Care (PC) specialists. During the surge of COVID‐19 patients, there was concern that large volumes and high acuity were barriers to ED physicians calling the helpline. To address this concern, we placed ophthalmology residents in the ED from 8am to 11pm each day to act as PC extenders, helping connect ED physicians, PC physicians, patients and families via telephone and video conferencing. The re‐deployed Ophthalmology residents coordinated goals‐of‐care discussions with patients, their family and PC specialists. Ophthalmology residents were chosen for this role for their clinical expertise and availability after the cessation of elective surgeries during the state of emergency. We sought to evaluate the number of PC connections made with this model.

Methods: We performed a retrospective review of admissions from the acute areas of our ED from April 6, 2020 to April 19, 2020. During the first week, only the 24‐hour helpline was available. During the second week, both the Palliative Care helpline and in situ residents were available. Number of Palliative Care notes from the ED were compared before and after the intervention.

Results: In the week when only the helpline was available 443 ED visits occurred, of which 169 (38.1%) were admitted and 10 (5.9%) had Palliative Care notes written in the ED. In the week when both the helpline and in situ residents were available 464 ED visits occurred, of which 131 (30.0%) were admitted and 36 (27.4%) had Palliative Care notes written in the ED.

Discussion: Compared to a telemedicine helpline alone, in situ PC presence in the ED increased the opportunity for early PC intervention, as reflected by an increase in the number of PC notes written in the ED. The residents did much more than just call the helpline. They video‐conferenced family meetings, held the video tablets so that family members, who were restricted by no‐visitor policies, could see family members. Sometimes they orchestrated the family’s ability to say a final goodbye. This model was an effective re‐tasking of specialized healthcare practitioners from a specialty that was less strained by the pandemic to one that was under pressure. Moreover, the numbers suggest that telemedicine alone was not sufficient to meet the needs of the patients and families during the pandemic surge. This suggests that telemedicine must consider the staffing required to set up and coordinate telemedicine connections with specialty services.

Presenting Author e‐mail: Jessica.Fleischer‐Black@mountsinai.org

34. A Qualitative Analysis of the Impact of Videoconferencing with the Premature Infant on Breast Milk Expression

Adrienne Hoyt‐Austin, DO, Iesha Miller, MHA, Kara Kuhn‐Riordon, MD, Jennifer Rosenthal, MD, MAS, Kristin Hoffman, MD, Laura Kair, MD, MAS

University of California, Davis Medical Center, Department of Pediatrics, Sacramento, California, USA

Background: Preterm infants have unique benefits from breastmilk including neurocognitive gains, reduced risk of sepsis and prevention of necrotizing enterocolitis. There are many barriers for establishing breastfeeding for these infants like poor oral readiness for feeds, distance from their mother, and a dependence on expressed breastmilk. In addition, breastmilk expression can be challenging and stressful. Thus, efforts to support breastmilk expression for mothers of premature infants are of great public health importance. One way to support a mother may be visualization of the infant during breastmilk expression. However, it is unknown if videoconferencing with ones hospitalized neonate improves the breast milk expression experience of women with hospitalized preterm infants in the neonatal intensive care unit (NICU).

Methods: In a randomized controlled trial (ClinicalTrials.gov Identifier: NCT03957941) with crossover design, mothers of premature infants were asked to visualize their infant during breastmilk expression during the intervention arm with use of videoconferencing technology. For the control, those same mothers expressed breastmilk without use of videoconferencing technology. We completed qualitative interviews with 12 participants who answered 14 open‐ended questions regarding their breastmilk expression experience when videoconferencing with their hospitalized preterm infant. Qualitative data were analyzed using inductive, thematic analysis with a constant‐comparative approach and responses were grouped into themes. At least three investigators coded each narrative response.

Results: Videoconferencing promotes bonding and connection with the hospitalized infant with one mother describing, “I like being near him. I like watching him…I think it [use of video conferencing] really does help just to connect to what I’m doing and why I’m doing it.” Videoconferencing also provides motivation, “When I see her more…I produce a little bit more…When I don’t see her…I didn’t produce not even half of the bottle. And when I’m with her or seeing her on the camera, I just ‐ just comes out.” Participants also described connection to the extended family where, “we have an older child at home and that’s how we introduced the new babies to him.” Viewing one’s infant also reminds women they are separated, “I think watching baby makes me feel closer than just pumping…for no reason and not feeling connected. But then it also makes me feel further, and it’s kind of sad to see baby like in the NICU and you’re not there to be able to like be with baby.”

Discussion: Videoconferencing with the hospitalized neonate improves the pumping experience mothers expressing milk for their premature infant. Further research is needed in factors that influence NICU families to use videoconferencing with their infants, barriers to use, and other benefits it provides to promotion of breastfeeding for this vulnerable population.

Presenting Author e‐mail: aehoyt@ucdavis.edu

35. Which Pediatric Interfacility Transfers are Opportunities for Telemedicine?

Selina Varma MD, MPH¹, Dana A. Schinasi, MD^1,2,4, Jacqueline Ponczek, MD, MS^3,4, Jacqueline Baca, BS⁴, Norma‐Jean E. Simon, MPH, MPA¹, Carolyn C. Foster, MD, MSHS^2,4‐6, Matthew M. Davis, MD, MAPP^4‐6, Michelle Macy, MD, MS^1,2,5

¹Division of Emergency Medicine, Department of Pediatrics, ²Department of Telemedicine, ³Division of Hospital‐Based Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Illinois, USA; ⁴Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; ⁵Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Illinois, USA; and⁶Mary Ann & J. Milburn Smith Child Health Research, Outreach and Advocacy Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois, USA

Background: More than 80% of children are treated in general emergency departments (EDs). Pediatric expertise has been centralized in pediatric hospitals and is associated with improved outcomes for specific conditions, but it has contributed to increases in transfers of children with common conditions by as much as 10‐15% per year. Telemedicine is effective for assessing acutely ill children prior to transfer and can reduce transfers from general EDs to pediatric intensive care units, but the potential for telemedicine to reduce some interfacility ED transfers is unknown. To inform telemedicine to reduce some interfacility transfers, we must identify which patients receive care that could be delivered in a general ED with pediatric emergency medicine (PEM) provider expertise via telemedicine. We aimed to describe children transferred from general EDs to a pediatric ED and discharged home and characterize patients whose care was potentially amenable to telemedicine, using an a priori definition.

Methods: We conducted a retrospective cohort study of patients < 21 years old transferred from general Eds to a pediatric ED and discharged home from 7/1/16‐6/30/17. Patients with a psychiatric or trauma diagnosis were excluded. Data abstracted from the referring and receiving hospital ED records included: demographics, diagnostic evaluation, interventions, and subspecialty consultations. PRISA2 scores were calculated prior to transfer to determine the probability of mandatory admission. Our primary outcome was care at the receiving ED that was potentially amenable to management via telemedicine, defined a priori as: 1) PEM provider assessment without other in‐person specialty consultation, 2) diagnostic evaluation considered available in a general ED (EKG, POC, or urine studies) or 3) interventions that could be performed in a general ED (oral medications, prescriptions, or referrals). Descriptive statistics were used to characterize the cohort. Chi‐squared statistics were used to compare characteristics of patients whose management fit our a priori definition to those whose management did not. A multivariable logistic regression was used to identify predictors of management amenable to telemedicine, but the sample size was insufficient.

Results: Of the 1,733 patients transferred, 454 (26%) were discharged home from the pediatric ED. One‐quarter (25%, n = 113) of those discharged met our a priori definition of having care potentially amenable to telemedicine, of whom 82% (n = 90) received their entire diagnostic evaluation prior to transfer and 53% (n = 60) received only a PEM provider assessment at the receiving pediatric ED. One‐ quarter of patients received a PEM provider assessment plus oral medications in the ED or prescriptions at discharge (29%, n = 33). Few patients (10%, n = 11) had a PEM provider assessment plus diagnostic evaluations that were readily available in a general ED. Compared with patients whose care was not amenable to telemedicine, patients whose care was amenable to telemedicine were more likely to be  < 2 years old (34% vs 18%, p = 0.007) and to have neurologic (30% vs 21%, p = 0.043), respiratory (17% vs 5%, p < 0.001) or urinary (5% vs 1%, p = 0.003) diagnoses. In contrast, patients whose care was considered less likely to be amenable were more likely to be 5 to 12 years old (30% vs 23%, p = 0.007) and to have gastrointestinal (38% vs 21%, p = 0.001) or reproductive (7% vs 1%, p = 0.013) diagnoses. There were no other statistically significant differences between the two groups.

Discussion: We found that one‐quarter (113 patients) of interfacility ED transfers that were discharged directly from our pediatric ED in one year fit our a priori definition of a visit potentially amenable to telemedicine. The majority of these patients received their entire diagnostic evaluation prior to transfer and a PEM provider assessment was the main form of care provided after transfer. While telemedicine is being increasingly used to provide pediatric critical care and trauma services prior to transfer, this study highlights an opportunity to provide PEM expertise outside of academic centers and reduce the transfer of some patients. Our findings have implications for reducing the financial and opportunity costs that result from interfacility transfer. Further efforts to understand the clinical care of children in general EDs as potentially amenable to telemedicine may strongly inform and influence the future design of pediatric telemedicine programs.

Presenting Author e‐mail: svarma@luriechildrens.org

36. Patient and Family Experience with Pediatric Specialty Telehealth Visits during COVID‐19 and Beyond

Sam Hanke, MD, Ken Tegtmeyer MD, FCCM, FAAP, Jen Ruschman, MS, Ciscily Sawyer, Linda Nourse, Michael Ponti‐Zins

Cincinnati Children’s Hospital, Cincinnati, Ohio, USA

Background: It was previously reported that 86% of families show interest in ongoing neurology telemedicine visits after receiving care using it during the pandemic (Rametta et al, 2020). Studies in pediatric urology subspecialty care has shown that telemedicine saves families time and money, likely increasing their satisfaction with care (Finkelstein et al, 2020). However, a broader view looking at telemedicine implemented across a pediatric academic medical center and evaluated using standard PFE (patient family experience) measures would add to generalizable knowledge.

Methods: We administered patient and family experience surveys via email and mobile methods (IVR and SMS) from March 23rd through June 21, 2020. This survey was administered via the NRC Real‐Time® survey platform. Families were sequentially contacted via email, SMS messaging, and automated phone call (IVR) up to three times. The 11‐question survey evaluated the experience of care and quality of technology specific to telehealth. Responses to the questions were anchored to either a four‐point scale “Yes definitely, Yes Mostly, Yes somewhat, No” or a 10‐point Likert scale for the overall rating of the service. After these questions, respondents have the option of leaving a free response comment. Percentage reported are for those responses with 9 or 10 out of 10 or chose the top box (Yes, Definitely). Analysis comparing telehealth experience to in‐person experience during the same time period was also conducted.

Results: The response rate for the survey was approximately 17.3% and over 3471 respondents were included in analysis. 84.3% of respondents rate the overall service a 9/10 on the 10‐point scale. The highest individual elements included trust in the provider (89.9%), Gave enough information (89.1%) and received the right treatment (87.0%). The lowest endorsed elements included telehealth saved the patient money (57.7%), quality of the video connection (64.1%), and method of connection was easy (72.8%). When compared to in‐person visits from the same time period, the in‐person overall rating of the provider scored 87.9% favorable vs 84.3% from telehealth. As we evaluated service line comparisons, we found several surgical service lines had overall scores for telehealth that exceeded their in‐person scores for clinic visits. Further, the service lines of adolescent medicine, rehab, sports medicine, and ophthalmology consistently saw telehealth scores below those of their in‐person visits Further, some specialties during COVID19 were forced to utilize telehealth for visits that may have been more suited for physical exam or hands on treatment.

Discussion: COVID19 pandemic created an opportunity where telehealth adoption was greatly accelerated. This analysis allows us to look specifically at patient and family experience in pediatric academic medical center, and across a variety of specialties. Overall, families had positive experiences with telehealth encounters across all specialties. We were able to realize some improvement in technical and ease of use over time. Additionally, PFE scores allowed us to target some specific provider training for things like agenda setting and wrap‐up that can influence experience with telehealth visits. Finally, while not a direct comparison for in person visits (ranking the provider) to telehealth visits (ranking of the service) this kind of analysis can give some directional influence to planning for optimization and offering of telehealth post‐COVID19, especially when enhanced with qualitative comments over time

Presenting Author e‐mail: Ken.Tegtmeyer@cchmc.org

37. Implementation of an Interprofessional 1‐800‐COVID‐19 Hotline Call Center Training Simulation

Kevin Sexton MD, Kathryn K. Neill, PharmD, FNAP, Jared Gowen, Kristen Sterba, PhD, Layla Simmons, MEd, RDCS, RDMS, Megan Lane, MHA, RT(R)(CT), RDMS, RVT, Joseph A Sanford, MD

University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Background: On March 13th, 2020 an academic health center suspended onsite classes due to the first confirmed case of COVID‐19 in the state. Faculty across 5 colleges (Nursing, Medicine, Public Health, Pharmacy, Health Professions) and the graduate school rapidly implemented alternative methods of instruction to complete coursework for the spring semester. The campus also delivers a 3‐phase (exposure, immersion, competence) interprofessional education (IPE) curriculum that is a graduation requirement. Interprofessional simulation training is a core immersion phase activity.

Methods: Concurrent to suspension of onsite classes, the health center instituted a 1‐800 COVID‐19 Hotline to support the public health emergency. The hotline provided rapid access to a health screening algorithm via a telehealth platform to assist the statewide community in understanding when and where they should access the health care system to seek testing or care for COVID‐19 symptoms. To support IPE delivery via alternative methods of instruction, previously scheduled onsite simulations were converted to an online platform and a new simulation was developed to address COVID‐19 disease information, screening algorithm and decision tree tools, and telemedicine care. The simulation format consisted of orientation (simulation training, Interprofessional Education Collaborative (IPEC) domains, and Patient‐ and Family‐Centered Care principles), interprofessional team review of screening algorithm and decision tree for preparation for patient encounter, standardized patient (SP) interaction, and debriefing. To design the SP interactions, a student pursuing combined medical and master in public health degrees drafted five case scenarios based on patient calls received during a call center shift.

Results: Three trainings were completed via Zoom^TM with 95 interprofessional students. Evaluation metrics include pre/post Interprofessional Collaborative Competencies Attainment Survey (ICCAS), evaluation of learning objectives via Likert scale, and identification of themes from qualitative response items. Descriptive statistics will be shared.

Discussion: An interprofessional simulation training activity via an online platform supported student learning for COVID‐19 disease information, screening algorithm and decision tree tools, and telemedicine delivery. The training also prepares students to serve in the 1‐800 COVID‐19 Hotline Call Center which supports the statewide community during this public health crisis. This program has the ability to be rapidly introduced during the pandemic.

Presenting Author e‐mail: kev@uams.edu

38. Rapid Implementation of an Interprofessional 1‐800‐COVID‐19 Hotline Call Center to Support a Public Health Crisis

Kevin Sexton MD, Kathryn K. Neill, PharmD, FNAP, Kristen Sterba, PhD Joseph Sanford, MD

Organization, City, State, USA

Background: In response to the first positive case of COVID‐19 in the state, an academic health center, instituted a 1‐800 COVID‐19 Hotline. The hotline provided rapid access to a health screening algorithm via a telehealth platform to assist the statewide community in understanding when they should access the health care system to seek testing or care for COVID‐19 symptoms and where they could access these resources. Faculty and staff from the Office of Clinical Informatics and Internal Medicine (Division of Infectious Disease), Institute for Digital Health and Innovation, Information Technology, and Division of Academic Affairs (DAA) collaborated to implement the call center within 48 hours of confirmation of disease in the state.

Methods: An evidence‐based screening algorithm evaluating symptoms, contact exposure risk, travel history, and high‐risk indicators was developed and a script and online survey for health information capture defined. Orientation and training for these tools was provided immediately prior to staffing. DAA took lead in identifying interprofessional student cohorts and staff for this rapid deployment community care resource. Students were able to use this activity to complete clinical or service training requirements disrupted by COVID‐19. DAA staff assumed lead roles to serve as administrators for call center staffing, trainers for new staffers, and room supervisors to ensure appropriate social‐ distancing and hygiene practices.

Results: From March 14^th to May 12^th, when the hotline transitioned to a virtual assistant, 10,937 calls were received (182 daily average) and 6,369 screening surveys (102 daily average) completed. 385 individuals from 5 colleges, the graduate school, DAA, and 3 clinical units completed 2,188 shifts. 74% of these individuals were students who provided 87% of staffing. Descriptive statistics for call volumes and staffing will be shared. Key successes and lessons learned will be highlighted.

Discussion: Rapid implementation of a 1‐800 COVID‐19 Hotline Call Center addressed an immediate patient/community needs for a public health crisis, supported student curriculum needs via alternative methods of instruction and practice, and supported student learning for COVID‐19 disease information, screening algorithm tools, and telemedicine delivery. Students were vital to the success and rapid implementation of this program.

Presenting Author e‐mail: kev@uams.edu

39. The Impact of PICU to ED Telemedicine on Changes in Severity of Illness

Dorwart, Elizabeth DO, MS, Felice Su, MD¹, Andy Wen, MD¹, Haley Hedlin, PhD², James Marcin, MD, MPH³

¹Department of Pediatrics, Division of Pediatric Critical Care Medicine and ²Department of Medicine, University School of Medicine, Stanford, California, USA and ³Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of California Davis School of Medicine, Sacramento, California, USA

Background: Telemedicine consultations was shown to decrease severity of illness scores compared to telephone consultations in one, small retrospective study. We hypothesize the use of telemedicine consultations will reduce severity of illness scores among patients transferred to a regional PICU in a prospective trial.

Methods: A prospective crossover‐cluster randomized controlled trial was conducted to compare telemedicine and telephone consultations conducted on seriously ill children. Patients age 0‐14, from 15 participating emergency departments were included if they were transferred to the regional PICU. Patients were randomized to either telemedicine or telephone consultations based on four 6‐month blocks. The Pediatric Index of Mortality (PIM) was used to assess severity of illness.

Results: 696 patients were recruited. Demographic data showed that groups were evenly distributed between telemedicine and telephone by sex, age, race/ethnicity. PIM‐2/3 scores were not significantly different between cohorts.

Discussion: There were similar reductions in severity of illness between the telemedicine and telephone cohorts. Analysis of RePEAT and PRISA scores are ongoing. More data is needed to understand how to optimize this technology in the post‐COVID era.

Presenting Author e‐mail: edorwart@stanford.edu

40. Evaluation of Providers’ and Parents’ Satisfaction with Neonatal Services Provided in a Level II NICU Utilizing Hybrid Form of Telemedicine

Gene Hallford PhD, Mike McCoy, CRNP, Edgardo Szyld, MD, MSc, Abhishek Makkar, MD

Division of Newborn Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center; Oklahoma City, Oklahoma, USA

Background: In 2013, the Department of Pediatrics’ Section of Neonatal and Perinatal medicine, located at the University of Oklahoma’s Medical Center, began providing specialty NICU care at Comanche County Memorial Hospital in southwestern Oklahoma with a hybrid telemedicine system. This system was developed to allow an off‐site neonatologist, typically located in Oklahoma City, to manage patient care by coordinating with an on‐site neonatal nurse practitioner (NNP). Unlike standard telemedicine programs, this particular initiative combined traditional patient‐physician care delivered in‐person three days per week with patient‐physician encounters delivered via telemedicine on the remaining four days per week. The implementation and overall success of this program has been published recently. Building on the success of our telemedicine program, this study aimed at evaluating providers’ and parents’ satisfaction with use of hybrid telemedicine system to provide intensive care at a Level II NICU.

Methods: Anonymous, non‐randomized surveys were given to the healthcare providers [Physicians (MDs), neonatal nurse practitioners (NNPs), nurses (RNs)] with experience in providing hybrid telemedicine services and parents of neonates who have participated in these services. Surveys were constructed using similar instruments in the published literature and were adjusted to account for differing roles of physicians, NNPs and nurses. Surveys used five‐point Likert scale questions, however responses are collapsed into 3 categories: 1) agree/strongly agree; 2) neutral/not sure; and, 3) disagree/strongly disagree. MD, NNP and RN survey’s findings are collapsed into “providers” group. Questions covered a range of issues, including telemedicine knowledge and understanding, perceived quality, its communication efficiency, and the quality of care delivered using telemedicine. IRB approval was obtained at the OU Medical Center’s IRB (# 11178) and Comanche County Memorial Hospital’s Research Committee prior to survey use.

Results: Nine physicians, 10 NNPs, 12 Nurses and 28 parents completed the surveys. In all, 84% of MDs and NNPs (N = 16) received training in and 83% of RNs (N = 11) were well informed about telemedicine use. 90% of providers (N = 28) found telemedicine effective for delivering advanced neonatal care and 90% (N = 28) believed it enhanced overall care quality. 84% (N = 26) found telemedicine reliable, 81% (N = 25) reported audio, and 87% (N = 27) video quality capable of high‐quality care. In all, 26 parents (93%) reported being well informed about telemedicine. 75% (N = 21) participated in physicians’ daily rounds, 96% (N = 27) were comfortable with their child’s physical examinations, and 93% believed privacy and confidentiality were respected and protected during telemedicine. Overall 79% (N = 22) reported good or excellent experiences with telemedicine. 86% (N = 24) reported good audio and 89% (N = 25) good video quality during telemedicine. When compared to providers, 82% (N = 23) of parents reported ability to communicate routinely with providers, whereas 90% (N = 28) of providers believed that they were able to communicate effectively with parents.

Discussion: Although implementation of a hybrid telemedicine system is complicated and requires extensive training, this service model is an effective alternative to transporting local patients to more distant magnate centers. Once trained, healthcare providers are satisfied with the overall quality of the system and the quality of care patients receive with this system. Also, when properly informed and meaningfully included, parents are satisfied with its use in the care and treatment of their infants.

Presenting Author e‐mail: Gene‐Hallford@ouhsc.edu

41. Telemedicine in Adult and Pediatric Neurology: Patient and Physician Perspective on Current and Future Use

Anne Marie Morse DO¹, Tessa Appleman, BS¹, Joseph Alario, DO², David Fletcher, MBA³

¹Division of Child Neurology, Pediatric Sleep Medicine^{, 2}Epilepsy Division and EEG Services, Division of Adult Neurology, and ³Center for Telehealth, Geisinger Health System, Danville, Pennsylvania, USA

Background: COVID‐19 is an unprecedented event that forced global shutdowns requiring healthcare systems to rapidly redesign and implement alternate care models, resulting in a massive increase in telehealth. Telehealth is the wide range of virtual services available to render various forms of healthcare delivery, with telemedicine referring to the remote audio/visual delivery of clinical services. Healthcare institutes are eager to “return to normal and reopen”. Reopening exposes a new knowledge gap, a need to identify the correct balance for safety, access and satisfaction without further financial sacrifice. Initial efforts focused on reintroduction of in‐person appointments, but long‐term changes incorporating telehealth are less well defined. To address this knowledge gap, we aimed to characterize the perception and effects of telemedicine within neurology, and develop future planning that incorporates the experience, opinions and suggestions of the key stakeholders.

Methods: This was a quality improvement initiative that did not require review by an Internal Review Board. A total of 51 neurology providers (11 pediatric and 40 adult providers were invited to complete an online survey about their telemedicine experience during COVID. The online survey consisted of 17 questions, using branching logic to avoid completion irrelevant questions for the responder. The survey evaluated perception of convenience, acceptance, impact on visit quality, decision making, as well as recommendations for future directions. The survey was started by 30 providers, completed by 27, partial completion by 2 and 1 disqualified due to non‐use of telehealth. A total of 115 patients/caregivers who had a telehealth appointment with adult or pediatric neurology in either March or April 2020 were randomly selected and called to participate in the patient survey. The survey evaluated perception of convenience, acceptance, visit quality, impact of COVID on desire to return to in‐person appointments, perception of limiting in‐person visits to examination‐only if needed to complement televisit, and request for recommendations for future directions. 45 patients were successfully contacted and completed the survey.

Results: 58% of providers started the online survey with 90% completed, 7% partially completed and 3% disqualified. Agree to neutral responses determined favor for statements presented (neutral response%). 96% of providers (7%) supported convenience of telemedicine. Acceptance was based on appropriateness for new and return patients. All providers supported use in returns (11%) and 64% for news (24%). 54% of providers disagreed that visit quality equal to in person. Despite this, 64% stated no difference in quality of care (10%) and 90% felt comfort to manage patients via telemedicine (11%). 40% of patients called were successfully contacted. All completed the phone interview. 100% of patients (11%) found telemedicine convenient. Acceptance of telemedicine (desire to use telemedicine again) was identified in 93% of patients (24%). 93% of patients felt they received the same care as in clinic (4% neutral). 91% of patients felt the quality as good as in person (29%). COVID concerns for in‐person visits were reported in 31% of patients. 96% of patients (38%) supported use of exam only visits as a complement to telemedicine. Recommendations included telehealth expansion, patient loaner devices, and virtual assistants to “room” patients.

Discussion: Response trends suggest telemedicine is convenient and acceptable. Perceived differences in quality were greater among providers than patients, with 58% of providers and less than 5% of patients reporting telehealth as inferior. Despite this, physicians endorsed quality of care and medical decision making were mostly unaffected. A positive telemedicine opinion appeared unaffected by COVID, as < 30% of patients stated this to avoid in person visits. The future of healthcare requires ways to maximize access, optimize satisfaction and maintain social distancing. Use of exam only visits as a compliment to telemedicine may be a solution. All patients will have prompt access to physicians via telemedicine, preserving access, expedited management, and social distancing while allowing an option for an exam. Services to consider include virtual assistants to enhance consistency/efficiency of visits, connected loaner devices for patients without internet or devices, and telehealth expansion.

Presenting Author e‐mail: amorse@geisinger.edu

42. What Drives Greater Assimilation of Telestroke in Emergency Departments?

Lori Uscher‐Pines PhD¹, Jessica Sousa², Kori Zachrison, MD³, Amy Guzik, MD⁴, Lee Schwamm, MD⁵, Ateev Mehrotra, MD⁶

¹RAND Corporation, Arlington, Virginia, USA; ²RAND Corporation, Boston, Massachusetts, USA; ³Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, Massachusetts, USA; ⁴Wake Forest School of Medicine, Winston‐Salem, North Carolina, USA: ⁵Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; and ⁶Harvard Medical School, Boston Massachusetts, USA

Background: Although many emergency departments (EDs) have telestroke capacity, it is unclear why some Eds consistently use telestroke and others do not. We compared the characteristics and practices of EDs with robust and low assimilation of telestroke.

Methods: We conducted semi‐structured interviews with representatives of EDs that received telestroke services from 10 different networks and had used telestroke for a minimum of two years. We used maximum diversity sampling to select EDs for inclusion and applied a positive deviance approach, comparing programs with robust and low assimilation. Data collection was informed by the Consolidated Framework for Implementation Research. For the qualitative analysis, we created site summaries and conducted a supplemental matrix analysis to identify themes.

Results: Representatives from 21 EDs with telestroke, including 11 with robust assimilation and 10 with low assimilation, participated. In EDs with robust assimilation, telestroke workflow was highly protocolized, programs had the support of leadership, telestroke use and outcomes were measured, and individual providers received feedback about their telestroke use. In EDs with low assimilation, telestroke was perceived to increase complexity, and ED physicians felt telestroke did not add value or had little value beyond a telephone consult. EDs with robust assimilation identified four sets of strategies to improve assimilation: strengthening relationships between stroke experts and ED providers, improving and standardizing processes, addressing resistant providers, and expanding the goals and role of the program.

Discussion: Greater assimilation is associated with standardized workflow, leadership support, ongoing evaluation and quality improvement efforts, and mechanisms to address resistant ED providers.

Presenting Author e‐mail: luscherp@rand.org

43. Treatment of Opioid Use Disorder during COVID‐19: Experiences of Clinicians Transitioning to Telemedicine

Lori Uscher‐Pines PhD¹, Sarah Hunter, PhD¹, Jessica Sousa, MSW¹, Pushpa Raja, MD², Ateev Mehrotra, MD^3,5, Michael Barnett, MD⁴, Haiden A. Huskamp, PhD³

¹RAND Corporation (Arlington VA, Boston MA, Santa Monica CA); ²Greater Los Angeles VA Medical Center, Los Angeles, California, USA; ³Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, ⁴Harvard T. H. Chan School of Public Health Boston, Massachusetts, USA; and ⁵Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Background: The COVID‐19 pandemic has transformed care delivery for patients with opioid use disorder (OUD); however, little is known about clinicians’ experiences rapidly transitioning to telemedicine. This study described how telemedicine was used in conjunction with in‐person care, barriers encountered, and implications for quality of care in the early months of the COVID‐19 pandemic.

Methods: In April‐June 2020, we conducted semi‐structured interviews with clinicians waivered to prescribe buprenorphine and practicing in a variety of outpatient settings (e.g., primary care clinics, opioid treatment programs, community mental health clinics). Maximum variation sampling was used. Standard qualitative analysis techniques, consisting of both inductive and deductive approaches were used to identify and characterize themes.

Results: 38 clinicians representing 15 states participated. Nearly all interview participants were doing some telemedicine, and more than half were only doing telemedicine visits. Most participants reported changing their typical clinical care patterns to help patients remain at home and minimize exposure to COVID‐19. Changes included waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits. Although several participants were serving new patients via telemedicine during the early weeks of the pandemic, others were not. Some clinicians identified positive impacts of telemedicine on the quality of their patient interactions, including increased access for patients. Others noted negative impacts including less structure and accountability, less information to inform clinical decision‐making, challenges in establishing a connection, technological challenges, and shorter visits.

Discussion: Buprenorphine prescribers quickly transitioned to providing telemedicine visits in high volume; nonetheless, there are still many unknowns including the quality and safety of widespread use of telemedicine for OUD treatment.

Presenting Author e‐mail: luscherp@rand.org

44. Experiences of Community Health Centers in Expanding Telemedicine: A Mixed Methods Evaluation

Lori Uscher‐Pines PhD, MSc, Jessica Sousa, Alina I. Palimaru, Mark Zocchi, Kandice A. Kapinos, Allison J. Ober

RAND Corporation, Boston, Massachusetts, USA

Background: Telemedicine can improve access to care for underserved populations. However, when telemedicine is offered in safety‐net settings, it tends to be a low volume service. To support the growth of telemedicine in large, multisite community health centers, the California Health Care Foundation (CHCF) invested in the Sustainable Models of Telehealth in the Safety Net (SMTSN) initiative, which was in place from 2017 to 2020. CHCF provided funding for nine participating health centers to hire and maintain dedicated telemedicine staff, created a learning community to facilitate peer learning, and offered technical assistance. Although this evaluation occurred before the COVID‐19 pandemic, the findings presented here are relevant to health centers that are trying to rapidly expand telemedicine in response to the pandemic, and the barriers and strategies identified are likely to have ongoing relevance once some of the changes in place for the duration of the emergency are rolled back.

Methods: We explored the following research questions: 1. What staffing, programmatic, and process changes were implemented to expand telemedicine? 2. What barriers did health centers face? 3. What was the impact of health center activities on telemedicine volume and realized access to telemedicine services? 4. Were high‐volume telemedicine programs and dedicated staff likely to be sustained and what factors contribute to sustainability? Quantitative data sources used in the evaluation included health center telemedicine volume and progress report data. Qualitative data sources included interviews with telemedicine staff and clinicians, which were conducted by telephone and at site visits, and focus groups with chief financial officers. In quantitative analyses, we first calculated descriptive statistics, comparing proportions using chi‐square statistics. We plotted the telemedicine volume data to assess changes in monthly volumes visually. Average monthly telemedicine volumes pre‐ and postintervention at each site and overall were compared using ttests. To assess whether the initiative changed the volume of telemedicine visits, we used an interrupted time series design. For the qualitative data, we identified themes.

Results: The most common approaches to expand telemedicine volume were to add new service lines, contract with new vendors, offer telemedicine services at new clinic locations, and purchase new equipment. Also, many health centers improved workflow, trained staff, and promoted telemedicine across the organization. The most‐common barriers included variable and insufficient reimbursement, technical difficulties, staffing challenges, insufficient physical space, and challenges working with remote specialists. In total, there were 53,135 completed visits across the 9 health centers. The most common telemedicine visit was with a behavioral health provider (48.3%), followed by visits with an ophthalmologist or optometrist (26.3%). Health centers reported that between 1‐9% (median of 3%) of all patients had at least one telemedicine visit in the final 6 months of the initiative. Overall, 3% of all health center encounters were telemedicine visits. Most health centers (8/9) in the initiative experienced a statistically significant increase in telemedicine volume. On average, prior to the initiative, health centers had 153 telemedicine visits per month. This increased to an average of 239 visits per month after the initiative (56% increase).

Discussion: The initiative was associated with the significant expansion of telemedicine in participating health centers. The initiative showed that, with a modest staffing investment, health centers were capable of rapid growth. However, ongoing challenges to implementation and sustained growth were identified. In the future, the financial sustainability of large telemedicine programs aiming to increase access to specialty care within community health centers likely will require more‐generous reimbursement policies across payers or from external revenue sources, such as grant funding. Furthermore, it appeared that, at the end of the initiative, telemedicine for specialty services was still benefiting only a small percentage of health center patients. Using the evaluation results, the research team developed several recommendations for health centers and policymakers to support telemedicine implementation

Presenting Author e‐mail: luscherp@rand.org

45. Updated Review and Two‐Year Analysis of the Pacific Asynchronous Telehealth System Impact on Military Pediatric Teleconsultations

Mechelle Miller MD, Kara Delaneya, MD, Charles Nguyena, MD, Jennifer Mbuthiaa, MD

Tripler Army Medical Center, Honolulu, Hawaii, USA

Background: The Pacific Asynchronous TeleHealth (PATH) system is an asynchronous provider‐to‐provider teleconsultation platform utilized by military medical facilities throughout the Western Pacific Region. This study focused on the growth of PATH utilization for pediatric cases, impact on transfer frequency to a tertiary medical center for evaluation, and cost avoidance for the Department of Defense through utilization of this teleconsultation platform.

Methods: This retrospective analysis reviewed cases from March 2017‐February 2020 for patients 0‐18 years old. Two survey questions included at the time of case closure asked the referring user about the impact on travel for in‐person specialty care or the need for local referral. Data for cost avoidance was estimated using established per diem rates and flights for fiscal year 2020.

Results: A total of 2448 pediatric consultations were submitted from 29 military medical facilities in 5 countries. General Pediatricians submitted 56.6% of consult requests (n = 1376) and patients aged 36 months – 12 years composed the highest proportion of consults (n = 1268; 51.8 %). Pediatric Pulmonology, Pediatric Cardiology, and Pediatric Neurology had the highest percentage of consults (n = 557, 24.5%; n = 446, 19.6%; and n = 236, 10.37% respectively). Median response time from specialists to consults was 16 hours. There were 1025 completed survey responses (41.9%) with 710 (69.4%) coded as preventing in person visits. Pediatric Pulmonology (n = 262), Pediatric Cardiology (n = 195), and Pediatric Endocrinology (n = 84) consultations were the most likely to prevent the need for face‐to‐face visits. By preventing these encounters, PATH saved approximately 2.5 million US dollars.

Discussion: The annual use of PATH for pediatric consultations has more than doubled since 2009. This asynchronous telemedicine platform is a vital asset in locations with limited access to medical specialists, or during times when travel restrictions can impact routine access, such as during pandemics. Primary care providers can seek expert consultation virtually, avoiding travel for in‐person routine specialty visits, which leads to a significant cost savings. This asynchronous model can be applied to civilian health care systems serving remote and underserved geographic locations by expanding the reach to pediatric specialists using a cost‐efficient provider‐to‐provider teleconsultation platform.

Presenting Author e‐mail: mechelle.a.miller.mil@mail.mil

46. Where Virtual Was Already Reality: The Experiences of a National Telehealth Service during the COVID‐19 Pandemic

Lori Uscher‐Pines PhD, MSc1, James Thompson², Prentiss Taylor, MD², Kristin Dean, MD², Tony Yuan, MD², Ian Tong, MD², Ateev Mehrotra, MD, MPH³

¹RAND Corporation, Arlington, Virginia, USA; ²Doctor on Demand, San Francisco, California, USA; and ³Harvard Medical School, Boston, Massachusetts, USA

Background: Large national telehealth services provide millions of telehealth visits per year. These organizations provide patients immediate access to clinicians via videoconferencing visits on personal electronic devices. When the COVID‐19 pandemic began, many physicians with limited experience with telehealth started offering telehealth visits to support social distancing. While research is emerging on their experiences,1 no research has explored virtual visits by large national telemedicine services. Did patients turn to these services in greater numbers? Did patients seek care for COVID‐19 related illness or other reasons? To address these questions, we describe the experience of a large telehealth service before and during the pandemic.

Methods: Doctor On Demand is a national telehealth company which delivers urgent care, behavioral health, preventive care, and chronic care services through relationships with self‐insured employers and health plans and directly to consumers. In March 2020, it observed an increase in requests for visits and pursued several strategies to increase capacity. Visits were captured from February‐June 2019 and 2020. In consultation with the external researchers, the data was generated by the company in aggregate form as percentage change from baseline. The baseline week was defined as February 25‐ March 3 for 2019 and February 24‐March 1 for 2020. We selected this week because it represented the tail end of influenza season and in 2020, occurred before significant community transmission of COVID‐19 in the U.S. We plotted changes in volume each week from baseline for all virtual visits and four categories: respiratory illness (including acute respiratory infections, influenza‐like‐illness, and potential COVID‐19); unscheduled behavioral health provided within the urgent care service; scheduled behavioral health (including therapy and psychiatry); and chronic illness.

Results: Compared to the baseline week, in 2019 total visit volume declined from March through June. In contrast, in 2020 visit volume grew from March through April 6, 2020 (59% above baseline) and then started to decline through the week of June 1 (15% above baseline). In 2020 in the baseline week starting February 24th, respiratory illness visits represented 45% of overall visit volume, whereas behavioral health and chronic illness visits comprised 20% and 5% respectively. Visits for respiratory illnesses increased and then declined during the study period (‐65% for the June 1 week). In contrast, unscheduled behavioral health and chronic illness visits increased over this period, peaking at 109% and 131% respectively before declining. In the June 1 week, respiratory illness visits represented 14% of overall visit volume, whereas behavioral health and chronic illness visits comprised 31% and 5% respectively. In 2020, all visits among urban residents peaked at 58% above baseline, while visits among rural residents peaked at 64% above baseline. Individuals from zip codes with a mean per capita income of < $20,000 participated in 47% of all visits in January and February vs. 50% in April.

Discussion: While the pandemic was associated with substantially increased overall utilization within this telehealth service, this growth was surprisingly not fueled by COVID‐19 concerns. It is unclear whether this new demand for behavioral health visits was driven by greater incidence of mental health concerns due to the stressors of the pandemic or because of reduced capacity of in‐person providers. Interestingly, overall telehealth visits peaked on the platform at approximately the same time that ED visits in the U.S. were at their nadir. This suggests that demand for telehealth in April 2020 may have been driven in part by patient hesitation to seek in‐person care. Prior work has recognized the important role that telehealth can play in a pandemic, helping to protect patients and clinicians from exposure and maintaining continuity of care.

Presenting Author e‐mail: uscherp@rand.org

47. How Much Does It Cost? Cost Calculation of the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) Call Center

Naleen Raj Bhandari, PhD, Yi‐Shan Sung, PhD, Wanda Whitehurst, Susan Fogelman, Hari Eswaran, PhD, Tina Benton, RN, Curtis Lowery, MD

Organization, Little Rock, Arkansas, USA

Background: The ANGELS Nurse Call Center (NCC) provides access to high‐quality perinatal and postpartum care to women across Arkansas since 2005. The NCC’s goal is to decrease the demand on emergency healthcare services, which will allow to maximize physician efficiency and productivity, and lower healthcare costs. However, there is limited literature on cost saving on healthcare via an NCC, partly due to scarce data on how much a call would cost. This study estimated a cost per call (minute) to enable a full cost evaluation of the ANGEL NCC.

Methods: This retrospective database study analyzed the NCC call data from August 2018 to March 2019 that were extracted from the EPIC‐based network (i.e., Mitel call system integrated with EPIC). We included all NCC calls that had “antepartum” or “postpartum” client types and those which had “telephone triage” as call types in the data. Calls in triage level I and II category were then used to calculate average time spent by type of staff: “front desk”, “phone nurse”, and “APRN.” Cost per call by the level of triage was estimated based on the amount of resources used in each call (i.e., sum of average time spent (minutes) by each NCC staff type*respective average salary (per minute) of the staff type). The average cost per call was used to calculate the total annual costs of operating the NCC. Fixed or sunk costs were excluded in this analysis.

Results: A total of N = 4,008 unique calls to the NCC were identified. The majority were Triage Level I (n = 3,761, 93.8%) and a very small proportion were of Triage Level II (n = 247, 6.2%). The median total call time for the Triage Level I and II was 14.6 and 18.9 minutes. For the Triage Level I, the median (IQR) time spent (minutes) per call by staff type were: 2 (2, 4) for “front desk staff,” 11.3 (7.6, 16.9) for “phone nurse,” and 2.3 (1.2, 4.2) for “APRN.” For the Triage Level II, the median (IQR) time spent (minutes) per call by staff type were: 3 (2, 6) for “front desk staff,” 13.4 (9.2, 24.3) for “phone nurse,” and 2.5 (1.2, 4.3) for “APRN.” The average total cost per call was estimated to be $11.29 and $13.34 for Triage Level I and II, respectively.

Discussion: The ANGELS NCC serves over 6,000 unique calls from perinatal and postpartum women across the state of Arkansas each year. Estimated cost per call is substantially lower, compared to in‐person visit in emergency department or urgent care, especially when including potential out‐of‐pocket spending and productivity loss. The ANGELS NCC has proved to a mean for obstetric services with a great value for Arkansas community.

Presenting Author e‐mail: NPayakachat@uams.edu

48. Potential Healthcare Cost Saving of the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) Nurse Call Center for Obstetric Services

Nalin Payakachat, PhD, Yi‐Shan Sung, PhD, Naleen Raj Bhandari, PhD, Wanda Whitehurst, Susan Fogelman, Hari Eswaran, PhD, Tina Benton, RN, Curtis Lowery, MD

University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Background: The ANGELS Nurse Call Center (NCC) for obstetric services was established in 2005 to allow experienced registered nurses to access to an on‐call maternal‐fetal‐medicine physician staff on 24/7 triage services. The NCC facilitates care to perinatal and postpartum women from all corners of the state of Arkansas. Despite benefits that are provided by the ANGELS NCC, the potential economic outcome has not yet been evaluated. The objective of this study was to estimate projected cost saving of the ANGELS NCC to the healthcare system associated with the ANGELS NCC obstetric triage services.

Methods: We conducted a retrospective study using the ANGELS NCC call data from 2016 and 2017 to estimate an average annual number of ED visits avoided. Average cost of ED visit was calculated using Arkansas Medicaid data for women who delivered their babies during 2015. We excluded ED visits that resulted in an inpatient hospitalization or under observation status. ED healthcare costs related to prenatal and postpartum (up to 42 days after delivery) were identified using the revenue codes (0450‐0452, 0456, 0459, 0981), the CPT codes (99281‐99285), or the place of service code (23). Average cost per ED visit from Medicaid’s perspective was then calculated by totaling all “paid amounts” for facility, professional service, and transportation claims. The potential 2‐year cost saving was estimated by multiplying the number of ED visit avoided with an average ED visit cost.

Results: Of N = 20,835 call, 1,268 (6%) calls were recorded with a pre‐disposition of “would have gone to ED”. A total of 596 (47%) out of 1,268 calls were recommended as “Go to ED now” or “Go to labor and delivery now” which left 672 potential ED visits avoided in the 2‐year period. We identified 8,928 pregnancy‐related ED visits for the 2015 calendar year. The mean paid amount per pregnancy‐related ED visit was $235 (SD = 180). The potential 2‐year cost saving for unnecessary ED visits avoided was estimated at $157,920. The projected cost saving only on ED visits avoided since the ANGELS NCC was incepted was substantial if these patients’ bills were paid by Medicaid.

Discussion: Our study showed that the ANGELS NCC potentially saved Arkansas Medicaid almost a million in the past 14 years for unnecessary pregnancy‐related ED visits. This potential savings estimate was conservative at the lower bound. The potential cost saving of ED visited avoided could be triple if we used a private payer perspective. This potential cost saving information of the ANGELS NCC for obstetric services is crucial to support the value of this type of service and to help policymakers better understand how valuable of the service to the healthcare delivery system.

Presenting Author e‐mail: NPayakachat@uams.edu

49. Scientifically Validated AI‐based Solution for Self‐Triage

Oscar Garcia‐Esquirol, Elvira Moreno Barriga¹, Irene Pueyo Ferrer², Miquel Sánchez Sánchez², Montserrat Martín Baranera³, Josep Masip Utset¹

Emergency Department, Hospital Clínic de Barcelona, Bareclona, Spain

¹Intensive Medicine Unit, Consorci Sanitari Integral; ²Emergency Department, Hospital Clínic de Barcelona; and ³Epidemiology and Research Department, Consorci Sanitari Integral

Background: Prospective observational study conducted in the Emergency Department of Hospital Clínic de Barcelona (HCB). This is a tertiary level (high complexity) 800 bed hospital, located in the city center, and reference hospital for a population catchment of 550,000 people approximately. At present, approximately 95,000 general emergencies are attended annually, excepting the specialties of obstetrics and gynecology, pediatrics and ophthalmology, which are performed in other centers. Since February 2009 the triage of patients in the emergency department is performed by nursing staff, using the allocation of level of urgency according to the Andorran Triage Model (MAT). The research was performed in a 4‐month period, from October 1, 2016 until January 31, 2017. The selected patients were those assigned MAT triage levels III, IV and V (which did not require immediate attention) in order of arrival and in different shifts to ensure obtaining a representative sample.

Methods: Observational, prospective study performed in the Emergency area of a tertiary university hospital. Patients with medical and surgical (including orthopedic pathologies) which did not require immediate medical assistance were given a tablet to answer Mediktor’s questioning. According to their answers, each patient was attributed a list of 10 pre‐diagnoses sorted by probability, which were concealed both from the patient as well as the attending physician, in order to avoid modifying the regular process. Subsequently, the degree of agreement between the medical diagnosis and the diagnoses offered by Mediktor was analyzed.

Results: 1,015 patients were surveyed, and 622 patients from this group were considered valid cases for analysis. Patients who did not meet the inclusion criteria, without a diagnosis on discharge, those who had their final diagnosis stated as a symptom and those with diagnoses not included in Mediktor were excluded from the study. Matches between the medical diagnosis (gold standard) and the 10 diagnoses of Mediktor was 91.3%, in the first three diagnoses was 75.4% and on the first diagnosis it was 42.9%. According to the most common diagnostic groups, sensitivity > 92% and specificity > 91% in most of them with a kappa index between 0.24 and 0.98 were observed. Mediktor is a reliable tool to help in the diagnosis of the most prevalent diseases found in an Emergency Service and it is easy to use by the general public.

Discussion: We carried out this study on Mediktor since, besides being a symptom evaluator using AI algorithms, it allowed us to perform the medical questionnaire without problems of understanding by users using natural language. After comparing the obtained diagnoses (physician & evaluator) it was observed that Mediktor had a high diagnostic match considering the list of 10 possible pathologies (ordered by probability) obtaining 91.3% with the diagnosis given by the Dr. In turn we were able to verify the high sensitivity (> 92%) and specificity (> 91%) of the evaluator. The patients were confident with the system and had no difficulties in answering the different questions that the symptom checker asked. Thus, more than 98% of respondents felt that Mediktor was an easy‐to‐use program. We consider that the results of our study provide relevant data that lead us to consider that Mediktor is an IT‐aided diagnostic tool that can accelerate the diagnostic process with improved efficiency.

Presenting Author e‐mail: vferrer@mediktor.us

51. Pediatric Palliative Care Remote Patient Monitoring Pilot Study

Tina Gustin, DNP, CNS, RN

The Children’s Hospital of the King’s Daughters, Norfolk, Virginia, USA

Background: Home‐based palliative care has become a model used by Accountable Care Organizations with the aim of reducing cost and resource utilization. Studies demonstrate a reduction in hospitalizations, emergency room visits, and improved patient and family satisfaction because of telepalliative care. Most of the studies, however, have been conducted in the adult population with industry focus on adult RPM equipment. A systematic review of pediatric telehealth palliative care services conducted in 2013 reported similar positive outcomes for the pediatric population. Unexpected readmissions were reduced, telehealth was generally accepted by families, the implementation was feasible, and it increased access to care. It should be noted that some of the early studies reported on phone call management rather than telehealth visits. Only one study investigated outcomes related to virtual home visits. Despite this need, most RPM equipment is designed for adults and not specific needs for children.

Methods: The Children’s Hospital of the King’s Daughters (CHKD) Pain and Palliative Care and Telehealth program partnered with a national RPM vendor that had never provided services for a pediatric population. The company provided 20 FDA approved devices at no cost; CHKD contracted to cover the monthly cost to maintain the device. The project was approved by the IRB for a 12‐month study period with a goal of enrolling 20‐30 pediatric hospice patients. The RPM was customized to the patient/family needs. Both PRN and scheduled visits with the Pain and Palliative Care team were conducted through the RPM tablet. A one group prospective pre‐post design was used to collect data on both patient and family outcomes. Data collected included customized dashboard communication, patient biometric data, parent confidence with technology, number of visits both virtually and in‐ person, and missed appointments, and provider satisfaction.

Results: The project was launched April 2020. There are 20 families enrolled in the study. Three families have 2 children receiving palliative care services; these families have two devices. The researcher will present the steps utilized to launch this new program. The first 6‐months of data and initial outcomes will be reported. Qualitative comments from the parents as well as the physician and nurse utilizing telehealth for the first time will reported. Important “lessons learned” will be discussed.

Discussion: Within 2‐weeks, 20‐families were enrolled. Because of the COVID‐19 enrollment and device teaching took place virtually. Early use was slow due to the learning curve. Currently 11 families are actively engaged providing weekly updates on their child. Nine families still intermittently provide weekly data. Engaged families overwhelmingly report that the “RPM devices and communication platform make them accountable for both their child’s care and communication with the provider.” Parents that previously welcomed the provider into their homes for in‐person visits are now requesting virtual visits. Because of COVID‐19 all families have pivoted to Zoom visits with other providers. Antidotally, families report they prefer communicating through the RPM platform verses Zoom visits. Lessons learned regarding pediatric RMP with adult companies and devices will be discussed. Discussions with the RPM vendor regarding the unique needs of pediatric RPM patients will be shared.

Presenting Author e‐mail: tgustin@odu.edu

52. Telesupervised Clinical Learning in Physical Therapy Education ‐ An Innovative Telehealth Model in Gait and Balance Community Clinic during COVID ‐19 and Beyond

Nupur Hajela PT, DPT, PhD, Na‐hyeon (Hannah) Ko, PT, DPT, PhD, Bryan Kwon, PT, DPT, GCS, Nancy Wubenhorst, MPT, Ellie Trask, PT, DPT

Fresno State University, Fresno, California, USA

Background: Impact of COVID ‐19 has been tremendous whether it is on health care education or health care delivery. Pandemic demanded sudden change in hands on clinical learning to virtual. The Commission on Accreditation in Physical Therapy Education (CAPTE) provided guidelines to deliver high impact practices in teaching and clinical learning in physical therapy academic programs. This allowed Clinical faculty to adapt and adopt telehealth within the framework of clinical education. Second year Doctor of physical therapy (DPT) students experienced for the first time providing a novel telehealth approach in the Virtual Gait, Balance and Mobility Community Clinic. The purpose of this study is two holds (1) to determine the effectiveness of telehealth physical therapy as an education model and as a mode of delivery of neurologic physical therapy (2) Assess the usability of telehealth by clients with neurological disorders by using telehealth usability questionnaire as a telehealth measure.

Methods: Five Clinical Instructors (CIs) telesupervised 17 doctor of physical therapy students. These doctoral students were grouped in groups of 2‐3 students in each group. In total, teletherapy sessions were provided to 14 patients over a Zoom platform for 30 minutes/session. These patients had a wide array of neurological disorders (For example: Stroke, Parkinson’s etc.) with gait balance or mobility related issues. Clinical instructors and students had in person interaction before switching to telesupervision mode along with providing telephysical therapy to patients. All patients underwent 4 telehealth sessions where students provided help with a home exercise program. First session was a zoom set up day along with familiarizing patients and student therapists with the patient’s home environment, going thorough safety measures such having a family member or caregiver nearby, having a chair next to them to hold onto or any other exercise equipment such as theraband. There was a tele‐debriefing session between CIs and students after every session to discuss how the treatment session went – what went right and what aspects of treatment implantation can be improved. The CIs and students also discussed the plan for the next week.

Results: Clients in the telehealth clinic completed a telehealth usability questionnaire. Online Learning experience by students was evaluated based on student provided feedback in the form of writing a reflection paper on their telehealth service learning experience. In addition, students were also engaged in discussion on a discussion board, which had telehealth related new topics provided every week on canvas ‐ the learning management platform. Clinical faculty played an active role throughout the process by asking thought provoking questions, asking students regarding policy changes around telehealth during a pandemic.

Discussion: Telesupervision along with teletherapy can be an asset to prepare the students and help them embrace changes during this pandemic. COVID‐19 has brought a paradigm shift in how we address our patient’s needs. We as clinicians and clinical instructors have to assess who among the patients are suitable for teletherapy. There are many factors that can help us make that decision: (1) age of the client (2) type of neurological disorder (3) stage of disease ‐whether it is stable and unstable (4) support of family and caregivers (5) patient’s level of motivation to recover (5) access to technology and viable internet connection. The technology comes with its own set of challenges but the benefits certainly outweigh the pitfalls in this era of social distancing where reducing contact with other individuals is the new normal that we are trying to come to terms with. The Pandemic is changing the mindset and is setting the tone in bringing telehealth to the forefront of healthcare delivery.

Presenting Author e‐mail: nhajela@mail.fresnostate.edu

53. Development of Resource‐Appropriate Telemedicine‐Augmented Mental Health Initiative In Rural Guatemala: “Colega A Colega”

Prashanth Fenn, Troy Sterling

University of Virginia School of Medicine, Charlottesville, Virginia, USA

Background: Globally, increasing mental health awareness in low‐resource countries has not led to concurrent improvements in mental health care. Guatemala’s crippling social stigma and poor resource allocation for mental health concerns underscore the significant disparity in care. No psychiatrists serve Totonicapan Hospital, a hospital that treats a population of over 500,000. When seeking mental health care, patients can only see the singular psychologist at the hospital or her clinical psychology students. If patient concern warrants a psychiatrist, they are referred to Federico Mora in Guatemala City, the only public psychiatric hospital in the country. When appropriately utilized, telemedicine can successfully bridge the accessibility gap between patients with mental illness and resource‐limited mental health professionals. We believe that establishing a link between UVA Psychiatry and Totonicapan Psychology will provide bidirectional educational opportunities and improve the quality of care.

Methods: Our team recently assessed the level of interest in the development of a collaborative, telemedicine‐based mental health initiative between UVA and Totonicapan Hospital. To evaluate the viability of such a partnership, we provided a 10‐question, written and oral survey to 124 health professionals and students at the hospital. The survey probed participant understanding and education in mental illness, as well as the system of care for mental health patients. We also assessed participant understanding of telemedicine and its implementation. Using these surveys, we assisted in piloting a telemedicine program involving bidirectional case‐study discussions between UVA Psychiatry and the Totonicapan psychologists.

Results: Our survey provided an important glimpse into the state of mental health care in Guatemala. The survey also identified several barriers to care for the patient population at Totonicapan. We discovered that most physicians who graduated before 2010 received no psychiatric/psychological courses during their medical education. Indeed, the majority of these participants state that no mental health education opportunities exist. Even now, medical students receive only rudimentary training and therefore are not confident when treating potential psychiatric patients. 60% of medical staff believed that mental health patients do not receive adequate attention at Totonicapán, citing the lack of a psychiatrist as the primary reason. Participants expressed great interest in telemedicine, and most respondents were quick to identify mental health concerns relevant to their department that can be addressed by telemedicine.

Discussion: The majority of participants felt that the mental health care and resources available were not adequate to properly treat patients. Based on the preliminary survey data, there is a strong interest in telemedicine utilization at Totonicapán Hospital. Telemedicine has the capacity for education and partnership in improving mental health care through peer‐to‐peer conferencing. This partnership has been maintained through monthly conferences and has established a means of education and promoting cultural competency for practitioners, both in Guatemala & UVA. As the program expands and awareness grows, this educational link has the potential to involve more physicians, students, and nurses from across the hospital departments and improve the quality of care for those suffering from mental illness.

Presenting Author e‐mail: PGF3HB@VIRGINIA.EDU

54. Pediatric Subspecialty Telemedicine use during COVID‐19 Pandemic: The Patient Perspective

Rajdeep Pooni, MD, Tzielan Lee, MD, Natalie Pageler, MD, Uptej Khalsa, MD

Stanford University, Stanford, California, USA

Background: Prior to the COVID‐19 pandemic, telemedicine use amongst pediatric subspecialties was uncommon. In part, this may have been due to unclear feasibility.

Methods: We performed a prospective, qualitative study of telemedicine visits across four pediatric subspecialties: endocrinology, nephrology, orthopedic surgery, and rheumatology at a large, tertiary care children’s hospital. Patients who were scheduled for a telemedicine follow up visits with their provider (between March 23and May 5, 2020) were consented to an interview regarding their video visit experience following their visit. A total of 40 patients (10 per specialty) were consented and 25 interviews were completed. Questions regarding the video visit process, the clinical visit, the follow‐up plan, and safety and needs in the setting of the recent COVID‐19 pandemic were asked. Interview audio was recorded and transcribed via recording software and thematic analysis was performed by pediatric specialty providers.

Results: The results of this study are pending—we are in the process of determining these patient‐derived themes around telemedicine use in pediatric subspecialty care.

Discussion: Though we are in the process of finalizing results, it is imperative to consider the patient perspective when it comes to telemedicine use in pediatric subspecialty care. The majority of the patients interviewed for this study follow with a subspecialist due to ongoing medical needs. Telemedicine is likely to be a part of continued pediatric subspecialty care, even following the pandemic, but future care models that incorporate telemedicine must include patients and their caregivers, especially in pediatric specialty care.

Presenting Author e‐mail: rpooni@stanford.edu

55. Reducing NICU Length of Stay and 90‐Day Readmissions Through the Use of Remote Patient Monitoring

Tanya Cahill, MD, Micah Dean, MBA

Cincinnati Children’s Hospital, Cincinnati, Ohio, USA

Background: Patients discharged from NICU with feeding tube and/or oxygen support are inherently at higher risks for adverse events including longer length of stay and readmission to the hospital. With newly established systems for Remote Patient Monitoring, patients from Cincinnati‐area regional NICUs were eligible to be enrolled. Families are provided with a scale and app on which they provide weekly weights and have access to nursing support 5 days/week. Specialized care in response to weights and any parental concerns is provided in real time following discharge to help answer questions and prevent further problems. Patients continue being followed by Cincinnati Children’s NICU Follow‐up clinic for in person visits throughout their enrollment period and beyond. Previous literature has suggested positive outcomes when using remote patient monitoring in neonates, but has been limited by study size or indication (Sasangohar et al, 2018).

Methods: Baseline data for patients sent home with feeding tubes and/or oxygen were obtained from the 24‐month period prior to RPM implementation. This information included gestational age, length of stay, method of feeding at discharge, and oxygen requirement at discharge and number of readmissions within 90 days. A case control matched analysis was used to look at the impact of remote patient monitoring during a 9‐month time period when remote monitoring was not used for all discharges. An analysis was performed to calculate the odds ratio for readmission and length of stay when comparing infants discharged with RPM to those discharged without RPM.

Results: 83 infants were enrolled in RPM between January 2019 and December 2019 ranging in gestational age from 23‐41 weeks. The majority of patients were feeding tube dependent at discharge. These were compared with 309 matched controls (gestational age and category of feeding tube, oxygen support or both)) from the baseline period. In the overall analysis, length of stay for initial NICU admission was reduced by an average of 10.0 days per patient. In addition, 90‐day readmissions were reduced by 50%. In the matched controls, the OR ration for 90‐day readmissions remained statistically significant at OR 0.32, 95% CI 0.15, 0.66 after controlling for initial length of stay.

Discussion: Significant reduction in readmission rate was seen in infants discharged from NICU using remote monitoring. This can translate into significant cost savings for an organization and health system overall. Further, with many NICUs being at capacity, the potential to reduce initial length of stay, could create significant capacity at regional NICU to better care for infants close to home. The additional support provided by the Remote Monitoring improves patient outcomes and decreases medical costs by reducing length of stay and decreasing readmissions. Expansion of these remote services after discharge should continue to be pursued.

Presenting Author e‐mail: tanya.cahill@cchmc.org

56. A Generative Co‐Design Framework for Virtual Care Innovation

Marissa Bird, BA, BSN, RN, PhD Student, Nancy Carter, RN, PhD, Audrey Lim, MD, Mike McGillion, RN, PhD

McMaster University, Toronto, Canada

Background: Innovation in virtual care models is essential for improving health outcomes, reducing costs, and integrating care for a better patient and clinician experience. One notable challenge in the virtual care innovation sphere is the notion of ‘pilot‐itis’, representing the plethora of virtual care innovation attempts that begin and end with the innovation pilot model, never reaching their full potential impact. One factor that may impede virtual care innovations from progressing beyond the pilot phase is a lack of attention to the needs of end users– typically represented in healthcare contexts as patients, their families, caregivers, and clinicians. Co‐design has been shown to be an effective means of incorporating end user views into healthcare innovation, yet a lack of clear guidance on how to operationalize co‐design techniques for the purposes of virtual care innovation exists.

Methods: Through our work with children with medical complexities, their families, and clinicians in designing and innovating a virtual care program, our group has created and validated a Generative Co‐Design Framework for Virtual Care Innovation to assist applied health services researchers, clinicians, virtual care innovators, and quality improvement specialists in operationalizing the principles of co‐design for virtual care innovation. Informed by a rigorous literature review and grounded in a theoretical model, the Generative Co‐ Design Framework for Virtual Care Innovation is a validated model for virtual designers seeking to include the voices of end users in their work. To develop this framework, our team, consisting of researchers, Family Partners, hospital‐ and home‐based clinicians, system navigators, and virtual care experts from the Ontario Telemedicine Network, undertook and documented a user‐led process for co‐designing a virtual‐enabled integrated care model for children with medical complexities and their families.

Results: This presentation will inform the audience of how to undertake a generative co‐design process for virtual care innovation using the Framework, from beginning to end. The seven steps of the Generative Co‐Design Framework for Virtual Care Innovation consist of: contextual inquiry, preparation and training, framing the day, generative design work, a share‐back session, data analysis, and requirements translation. In addition to outlining the 7 steps, relevant examples of operationalizing the Framework in our own project will be shared.

Discussion: Virtual care innovation is a necessary for ensuring a sustainable, cost‐effective, and high‐quality healthcare system. Inclusion of end‐user voices via co‐design may help virtual care designers to create relevant and useable virtual care innovations, ultimately contributing to their acceptability and adoptability. Using the described Generative Co‐Design Framework for Virtual Care Innovation, virtual care designers can effectively operationalize the principles of co‐design in healthcare innovation, increasing their chances of spreading and scaling effective virtual care models.

Presenting Author e‐mail: birdm3@mcmaster.ca

57. Telehealth Certification for Educators and Providers

Tina Gustin DNP, CNS, RN, Carolyn Rutledge PhD, FNP‐C

Center for Telehealth‐Innovation, Education and Research, Old Dominion University, Norfolk, Virginia, USA

Background: Prior to COVID‐19, telehealth (TH) adoption remained limited due to restrictions and limited provider preparation. Due to COVID‐19, most professions transitioned rapidly to telehealth. Universities halted in person education and removed students from clinicals. Providers were using TH without knowledge or experience. Faculty were left without the knowledge or skills to prepare students for TH. Prior to COVID‐19, faculty at Old Dominion University’s Center for Telehealth‐Innovation, Education, and Research (C‐TIER) developed a robust interprofessional (IP) telehealth curriculum based on their model “The Four P’s of Telehealth:” 1) planning, 2) preparing, 3) providing, and 4) performance evaluation that guided training/competencies. The program utilized pre/post‐as well as a series of TH training videos produced by C‐TIER and utilized for demonstrating TH etiquette and assessment skills. This program was transitioned to a 2‐week IP TH Certificate/CEU program for faculty and students.

Methods: Asynchronous content included narrated presentations, videos, and readings. Participants were guided through 8‐modules with a quiz at the completion of each to validate learning. Students were placed in groups of 4 with 1 faculty member to develop proposals for the integration of telehealth within their specific profession. Four of the groups were then added to a larger cohort enabling the learners to hear the presentation of participants from 4 other professions. This allowed the learners to experience telehealth from an interprofessional perspective. A final activity enabled students to conduct videoconferencing encounters with classmates of differing professions. Groups of 4 students each participated as a patient, provider, and evaluator of telehealth etiquette, and evaluator of telehealth delivery. Pre/Post data was collected to determine their knowledge, comfort, and understanding of telehealth etiquette. The program was evaluated at the end of the program. Focus groups with students and faculty are currently being conducted to both evaluate, refine, and adapt the certificate program. From this feedback, the program will be refined and then offered to additional providers/educators over the next year.

Results: The inaugural certificate program was delivered in June to 129 students and 50 faculty from universities throughout the United States. Participants included students and faculty from professions such as: advanced practice nursing, nurse executives, clinical counseling, physical therapy, athletic training, dental hygiene, speech and language pathology, and human services/case management. The course ended June 28, 2020. Data from the instruments are currently being evaluated and will be presented. Participant evaluation as well as qualitative data from the focus groups will be presented.

Discussion: The certificate program was filled within one‐week of advertising. There is currently a waiting list for the next offering. The faculty/researchers were initially concerned that participants would not want to participate beyond the asynchronous content. Interestingly the participants felt that this was one of the more beneficial experiences; they expressed that the 2‐activities solidify the learning. They enjoyed the ability to discuss telehealth with peers and those from other professions. Many of the students commented that they did not think that telehealth would apply to their profession, however; they now saw it as vital for their profession. The results suggest that comprehensive telehealth education should focus on more than just delivering telehealth but also planning and preparing for its delivery. Programs such as this can serve as a model for preparing both faculty and providers.

Presenting Author e‐mail: tgustin@odu.edu

58. Designing for Quality in Direct‐to‐Consumer Pediatric Telehealth Service

Victoria Ames, MPA, Scott Reeves, MD, Michelle Widecan, DNP, APRN, CPNP PC/AC, CPEN Jennifer Ruschman, ScM, Ken Tegtmeyer, MD, FCCM, FAAP

Cincinnati Children’s Hospital, Cincinnati, Ohio, USA

Background: Direct to consumer telehealth services have been available for years and are growing in utilization. Concerns around quality of these services have surfaced, specifically related to antibiotic prescribing in children with upper respiratory infections (Ray et al., 2019). Little information is available around other quality measures in pediatric direct to consumer telehealth such as prescribing rates across various indications, adherence to in person care recommendations, and PCP communication

Methods: We obtained data from both the vendor portal as well as our electronic medical records system. We evaluated descriptive statistics for rates of communication with PCP. We stratified by patient/family indicated reason for visit and looked at oral antibiotics prescriptions across various indications and report on rates. We used EMR to look at presentation to Urgent Care or Emergency within 48 hours of direct to consumer visit to evaluate adherence to care and resolution rates.

Results: The top five chief complaints as indicated from patients/families were Rash, Virus, Fever/Flu, Cough/Congestion/Cold and Eye Infection. Antibiotic prescribing rates were reviewed based on chief complaint. Prescription rate for Rash was 47% (46 of 97 patients), Virus was 0% (0 out of 74 patients), Fever/Flu was 13% (7 out of 54), Cough/Congestion/Cold was 21% (10 out of 47) and Eye Infection was 5% (2 out of 38). We found that in 74% of cases, we were able to successfully identify and send communication to the patient’s primary care physician. We also found that adherence to the recommendation to seek immediate urgent or emergent care was followed 100% of the time (10 out of 309 cases). Conversely, 1.3% of patients presented to ED or urgent care within 48 hours of initial direct to consumer telehealth visit, possibly due to worsening or unresolved symptoms. We do not have data on PCP follow‐up within 48 hours.

Discussion: Key components in designing a quality pediatric direct to consumer telehealth service includes adherence to best prescribing practices, supporting the patient‐centered medical home (PCMH), and ability to see case resolution as well as appropriately refer patients for in person care when needed. We demonstrate that we were able to resolve the majority of cases without urgent or emergent intervention, we are able to measure prescribing rates across indications in order to compare with clinical best practices and adjust clinical protocols as needed, all while providing consistent communication with the patient centered medical home. The visits also did not result in excessive ED visits or returns to clinic.

Presenting Author e‐mail: victoria.ames@cchmc.org

59. Telestroke Quality Assessment Surveys; Our Plan for System‐Wide Assessment

Aliza Brown PhD¹, Sanjeeva Onteddu, MD¹, Krishna Nalleballe, MD¹, M. Christine Arthur, MS², Marzella Backus, MS, RN¹, Renee Joiner, MS, RN³, Clin Prog Dir, Curtis Lowery, MD³

¹Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

²NY Instit of Tech, COOM, Arkansas State University, City, Arkansas, USA; and ³Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Background: Stroke is the 5th leading cause of death and the leading cause of disability in adults in the US. While the national rate of stroke‐related deaths and disability are on a decline; there are however marked disparities in stroke care between rural and urban communities and mortality. Emergence of telestroke networks are bridging such disparities in rural communities. The UAMS Institute for Digital Health & Innovation (IDHI) – Stroke Program, comprised of 54 telestroke spoke sites, services the most rural areas. Since the telestroke programs start in 2008 we have seen dramatic improvements in stroke care and significant reductions in stroke mortality. During this 12‐year period the program relied on suggested improvements by participating sites and their care teams. To achieve a full program quality assessment (QA), surveys were developed for patient consults, participating site nurse facilitators and their emergency department (ED) physicians, and consulting tele‐neurologists.

Methods: Four QA surveys (consults, nurse facilitators, ED physicians and tele‐neurologists) were needed for determination of systemwide improvements. All survey results are confidential and results de‐ identified. Those patient/consults (or their family/caregivers) who received tele‐based consults have a one‐time survey sent by text message at 4 days initially. At later dates, new patient/consults will receive a one‐time survey at 7 or 30 days for evaluation of the #days that produces highest reported return. All survey questions were developed with Qualtrics XM (Experience Mgmt Software, Provo UT). Nurse facilitators and their emergency department (ED) physicians were emailed monthly surveys for education, audio/visual and satisfaction with the telestroke program. Quarterly surveys sent to the tele‐neurologists were designed to measure their level of satisfaction with the program and interaction with spoke care teams.

Results: Four surveys were built around QA for a telestroke program to provide systemwide improvements. Each survey took into consideration the audio/visual aspect and interactions with nurses, ED physicians and the tele‐neurologists. Patient/consult surveys took into consideration their informed decision making and their perceived ability to receive care at local hospitals. For the care teams (nurses and ED physicians) questions of education and training were incorporated. For the tele‐ neurologists, questions on interaction with the care teams were included.

Discussion: These surveys may have edits incorporated over time or changes in delivery date for improvement in number of responses and quality of results. Surveys recently sent to the nurse facilitators were well received and have suggestions for education improvements.

Presenting Author e‐mail: brownalizat@uams.edu

60. Telehealth Outcomes Research: Show Me the Data

Jillian Harvey MPH, PhD, Dee Ford, MD, MSCR, Kathryn King, MD, MHS, Rebecca Beeks, MHA, Ryan Kruis, MSW, Kit Simpson, DrPH, James McElligott, MD, MSCR

Medical University of South Carolina, Charleston, South Carolina, USA

Background: More rigorous telehealth evaluations are needed. Many telehealth programs rely on simple counts of programmatic data, and never advance to assess higher‐level outcomes.

Methods: Using established evaluation methods and observations from telehealth delivery we developed an applied measurement framework. We describe active telehealth services and report metrics that can be implemented across stages of telehealth maturity.

Results: We present a measurement approach based on levels of telehealth maturity: 1) pilot, 2) scaling‐up, 3) established program, and 4) optimized program. For each stage, we identify appropriate metrics, data sources and evaluation tools.

Discussion: The measurement framework is generalizable across telehealth modalities, service lines, and technology. Telehealth evaluations should match the maturity of the program to appropriate outcomes.

Presenting Author e‐mail: harveyji@musc.edu

62. Pursuing Methodological Clarity in Telehealth Effectiveness Research

Jonathan Neufeld PhD

University of Minnesota Institute for Health Informatics and Executive, Minneapolis, Minnesota, USA and Great Plains Telehealth Resource and Assistance Center, Minneapolis, Minnesota, USA

Background: There is a persistent sense that researchers (as well as payers, legislators, and regulators) are trying to determine whether and under what conditions telehealth is effective. Several large analyses and reports are available that summarize the evidence amassed to date, and new studies are frequently undertaken to examine the application of telehealth to new populations, specialties, and treatments. Despite consistently optimistic reports, the “hard” evidence still appears to be inconsistent and equivocal. One may reasonably begin to wonder whether we will ever get a final answer to the question of telehealth’s general effectiveness. The current study was undertaken to explore this situation in greater detail, and determine if there are unrecognized methodological barriers inherent in our current methods.

Methods: A selection of well‐known and highly regarded published studies and reports was reviewed with the goal of describing the evidence collected in support of telehealth’s effectiveness. These reports include: (1) National Quality Forum Framework for evaluating telehealth (2017), (2) MedPAC reports on Telehealth in Medicare (2016 and 2018), (3) Cochrane Review of the Effectiveness of Telehealth, and (4) Multiple scholarly reviews and meta‐analyses on the effectiveness of telehealth for various medical and psychiatric conditions. Multiple scholarly reviews and meta‐analyses of the effectiveness of in‐person, traditional care for the same or similar conditions. The evidence reviewed by these studies and reports was characterized with regard to the conditions studied, the research designs, and the expected effectiveness of the underlying clinical interventions.

Results: Findings indicate that telehealth interventions tend to be conceptualized as clinical interventions, but are actually systems‐level interventions that are highly reliant on local, idiosyncratic processes for their effects. Telehealth interventions usually aim to alter these local processes, but generally do not affect actual clinical treatments other than by increasing, systematizing, or otherwise affecting the conditions of access. Furthermore, variation in the baseline efficacy of the underlying clinical treatments appears to account for the significant variations in effectiveness found among telehealth studies. For example, if a treatment is only 50% effective in person, then it can never be more than 50% effective when delivered via telehealth. Highly efficacious treatments that are sensitive to timely access (e.g., stroke) tend to show the greatest effectiveness for telehealth trials. Thus “telehealth” impacts clinical outcomes across a population by facilitating access (in timeliness, regularity, or some combination) in response to specific local conditions. Such conditions always include idiosyncratic barriers, and may include other, more general barriers to care.

Discussion: Telehealth interventions generally aim to alter specific local processes, and affect outcome primarily through facilitating access. Telehealth itself does not have an independent effect on outcomes, but rather functions as a potential mediator of outcomes via its effect on access to an established treatment. The ultimate effect of a telehealth‐driven intervention is limited by the prior effectiveness of the treatment being facilitated, the degree to which improved access is linked to improved outcomes, and the degree to which access is improved by the specific intervention in the specific local conditions. Taken together, these findings suggest that telehealth can never be declared effective in the general sense, but that local applications of telehealth will have their own specific effects, and must be individually evaluated. Telehealth researchers should recognize this situation and design and report their trials accordingly.

Presenting Author e‐mail: jneufeld@umn.edu

63. Challenges of Leveraging Video‐to‐Home Technologies to Deliver Care for Frail Older Adults during the COVID‐19

Avi Lamba¹, Stuti Dang, MD, MPH^2,3, Willy Valencia‐Rodrigo^3,4, Kiranmayee Muralidhar, MBBS, MPH², Diana Ruiz, RN⁵

¹Flint Hill School, Oakton, Virginia, USA; ²University of Miami Miller School of Medicine, Miami, Florida, USA; ³Miami Veterans Affairs (VA) Healthcare System, Miami, Florida, USA; ⁴Florida International University, Miami, Florida, USA; and ⁵Frailty Clinic, Miami, Florida, USA

Background: The COVID‐19 pandemic has forced the United States (US) healthcare system to suddenly and dramatically change how care is delivered. Telehealth offers immense benefits for the geriatric population during COVID‐19, since older adults with multiple chronic conditions are at high risk for COVID 19 infection and poor outcomes, and make up the majority of deaths due to COVID‐19 in the US. The Veterans Health Administration (VA) has also been nimble in leveraging its technological capabilities and in transforming routine face to face care to virtual, so that clinicians could continue to care for patients by converting face to face office visits to virtual. This pivot to virtual care greatly limits travel and exposure and permits uninterrupted care of patients. This is possible only if the veteran and caregiver have the tools, ability, and willingness to use technology. However, the exact numbers of veterans able and willing to use technology for video‐to‐home visits are unclear.

Methods: A VA Frailty Geriatric Specialty Clinic for frail older veterans with multiple chronic conditions pivoted to offer video‐to‐home visits to clinic patients. We called patients to schedule follow‐up appointments. We used a screening tool to determine those who were able and willing to use video‐ to‐home technology.

Results: Of the 81 patients we attempted to reach, 49 answered their telephone. Of the 49, three said they preferred to be seen in person. Forty‐six patients were scheduled for virtual visits by video‐to‐home or telephone; 26 of the 46 (57%) reported having equipment at home that would allow a video‐to‐ home visit, i.e., computer with a camera or a smart phone, and a data plan. Of these 26, four (15%) were scheduled for telephone visit based on personal preference; 22 (85%) were scheduled for a video‐to‐home visit, 4 of the 22 (18%) visits had to be switched to telephone due to connectivity issues during the call, and one no‐showed. Of the 46, 20 (43%) did not have equipment for video visits and therefore scheduled telephone visits. Of these, one person cancelled due to having issues with hearing aids and two were no‐shows. Only 17 (35%) of the original 49 frail older patients reached were able to complete a video‐to‐home visit.

Discussion: Only a third of frail older patients completed a video‐to‐home visit successfully. There is significant variation in the ability of frail older adults to have access to and use video‐to‐home technology, despite the presumed narrowing digital divide. Many patients still choose telephone visits over video to home. Connectivity is an issue even in urban areas. These data demonstrate the tremendous challenges of leveraging video‐to‐home technologies to deliver care for frail older adults during the COVID‐19 era. While the broad shift to telehealth enables health professionals caring for older adults to minimize the risk of exposure or infection for vulnerable older patient population, there is a need to study the proper balance between virtual and in‐person care, especially for older patients with complex needs.

Presenting Author e‐mail: alamba@flinthill.org

64. Integration of a Checklist to Assess Telehealth Etiquette in an Online Training Program

Beverly W. Henry PhD, RDN, Tina Gustin, DNP, CNS, RN, Carolyn M. Rutledge, PhD, FNP‐BC

Old Dominion University, Center for Telehealth-Innovation, Education & Research, Norfolk, Virginia, USA

Background: In the past decade, hospitals implementing telehealth (TH) programs more than doubled and consumer acceptance, cost, ease of use, and quality outcomes improved. With COVID‐19, TH services rapidly expanded impacting how clinicians, students, and educators provide health care. Also, regulations about TH services broadened on all levels. This situation prompted educators and professional associations to revisit training standards for health professionals. While there is a preponderance of guidelines for technical and disciplinary‐specific procedures, we lack information about how to develop proper telehealth etiquette and how to measure clinician behaviors. Evaluation methods to assess TH etiquette and allow for quality improvement are needed to ensure that clinicians are prepared to provide effective patient care.

Methods: In this presentation, we will describe how we used the checklist in an education setting in a collaboration between two universities and two professions, Registered Dietitian and Advanced Practice Nursing. The TIPS‐TC was developed through a multi‐method design at NIU through literature review, SME survey, and pilot testing with multidisciplinary practitioners. The TIPS‐TC consists of 12 items on a five‐point rating scale. Items represent subskill areas with two to five underlying observable behaviors to represent TH orientation, communication, relationship building, and environment. The Center for Telehealth‐Innovation, Education and Research (C‐TIER) at Old Dominion University, developed seven telehealth training videos to demonstrate different levels of telehealth etiquette (excellent, adequate, and poor). Two videos depicting an excellent and a poor version of one scenario offered an opportunity to compare providers’ behaviors related to telehealth etiquette using the TIPS‐TC. This June we integrated the TIPS‐TC and the two versions of a TH scenario into a two‐week long online training program developed by C‐TIER. We also applied the TIPS‐TC a second time to evaluate the performance/skills of participants in TH simulations.

Results: Participants in the C‐TIER online training program included 179 individuals from across the United States with students (N = 129) and faculty (N = 50 faculty). Progression through the program was based on completion of short quizzes on content areas and small group projects. Data from the TIPS‐TC includes quantitative results on the five‐point scale for the 12 items representing subskill areas and qualitative data from coaching comments added by participants as available. Since the online program ended in June, data from students’ completion of the TIPS‐TC in the course are currently being analyzed. The results from the TIPS‐TC evaluation instrument will be provided during this presentation.

Discussion: With our collaboration, we enhanced newly developed learning activities with usable assessment strategies. Integration of the TIPS‐TC in this online program met a two‐fold purpose. 1) to assess the usefulness of this instrument when applied in a training program to ensure that we met program directors’ goals. 2) the TIPS‐TC provided a forum for feedback on participant skill levels with telehealth etiquette. The TIPS‐TC was founded in social presence theory to exemplify clinician behavior at desired levels of computer‐mediated communication. The TIPS‐TC was easily integrated within the online training program. It provided a unique approach for both educating and evaluating learners regarding telehealth etiquette knowledge and skills. The videos and TIPS‐TC provided an asynchronous modality that could be embedded into any learning platform. Session participants will be familiar with and have access to the two videos of a TH scenario demonstrating TH etiquette, the TIPS‐TC for future use.

Presenting Author e‐mail: bwhenry@niu.edu

65. Barriers to and Facilitators of the Adoption of Telehealth among Healthcare Providers in Mississippi: A mixed methods study

Michelle Williams PhD, MSPH, MPH, MCHES¹, Tearsanee Carlisle Davis, DNP, FNP‐BC²

¹George Mason University Department of Global and Community Health, Fairfax, Virginia, USA and ²Center for Telehealth, University of Mississippi Medical Center, Jackson, Mississippi, USA

Background: People living in Mississippi have the lowest life expectancy in the nation. The excessively high number of medically underserved areas in the state is a primary contributor to poor health outcomes that lead to premature mortality. Continuing the expansion of telehealth services in Mississippi is vital to reducing disparities in health outcomes among people in medically underserved areas. The goal of this study was to identify factors that influence healthcare providers’ decision to adopt telehealth. The conceptual model for this study was based on the Diffusion of Innovations theory and the Levels of Use dimension of the Concerns‐Based Adoption Model.

Methods: A convergent parallel mixed methods study design was used to conduct this study. Healthcare providers (n = 80) in Mississippi were invited to complete an online survey. Scales from Rogers’ Adoption Questionnaire were used to assess the providers’ perceived attributes of Telehealth including the relative advantage, complexity and observability. A subset of the survey participants (n = 9) were selected to participate in telephone interview. The Levels of Use dimension of the Concerns‐Based Adoption Model was used to develop the semi‐structured interview guide. Linear regression was conducted to test the effect of providers’ characteristics, (graduation year, length of time as a health provider, age range of patients served, and weekly clinical hours) on their perceived attributes of telehealth. The qualitative data was analyzed using open‐coding, followed by focused coding of the emerging themes.

Results: The majority of the participants (64%) were not current users of Telehealth. The participants had worked as healthcare providers for an average of 10.02 years (SD = 8.3 years, range; 1 year – 35 years). Most participants were either family nurse practitioners, nurse practitioners, or physicians. Awareness of telehealth was statistically significantly higher (p  <  0.001) among healthcare providers whose patients are primarily adults compared to those whose patients were children. Awareness of Telehealth was also statistically significantly higher among healthcare providers who had been working in the field longer and who spent more hours per week providing clinical care (p = 0.04 and p = 0.034, respectively). Qualitative data from the semi‐structured interviews supported the quantitative findings that Telehealth was used more often by providers who had been working in the field for an extended period of time. Participants suggested that seasoned healthcare providers are more adept at providing care via telehealth due to their extensive experience. The qualitative data also revealed that practitioners who provided care to patients under the age of 18 were more likely to be in the orientation or preparation phase of Roger’s Adoption Process. They were most commonly planning to provide behavioral health services via telehealth to patients under the age of 18.

Discussion: The results of our study indicated that interventions aimed at increasing awareness of telehealth should be targeted towards healthcare providers who are new to the field. In addition, in Mississippi, there is a need to increase the use of telehealth by providers whose patients are primarily under the age of 18. The results of this study will be used to inform the development of strategies aimed at increasing the adoption of telehealth by healthcare providers in Mississippi. Healthcare providers who have been working in the field for many years, and who are in the later stages of Roger’s Adoption Model (i.e. integration) should be called upon to lead efforts to enhance their nascent colleagues’ awareness and adoption of telehealth.

Presenting Author e‐mail: mwill29@gmu.edu

66. Paternal Participation in Rounds Using Telehealth

Anirudha Das, MD, Ajith Mathew, MD

Cleveland Clinic Children’s Hospital, Cleveland, Ohio, USA

Background: Previous research has shown that the father of infants admitted to the Neonatal Intensive Care Unit (NICU) is stressed as a result of fulfilling the traditional role as a breadwinner as well as caregiver. Due to Coronavirus disease 2019 (COVID‐19) pandemic, the parental visitation policy in our hospital changed. The new policy allowed only one parent to visit the NICU at one time. This was necessary as part of the initiative to enforce social distancing and keep families and providers safe and prevent them from contracting the disease. During family‐centered rounds in our NICU, only one parent (usually the mother) was able to be present. At that time, multiple fathers had expressed the disappointment and frustration at not being able to be present during the morning rounds. We utilized a teleconferencing platform to involve the fathers in the morning rounds.

Methods: The teleconferencing platform zoom was utilized for the program. During the weekdays before the rounds, the father was sent a link with a password to join the rounds. The father was informed of the approximate time of rounding and requested to log in to the platform 10 minutes prior. At the time of the rounding, the Physician (who was the team leader) was able to check if the father was available in the virtual waiting room in the platform. If the father was present, he was checked into the live stream and participated in the rounds.

Results: So far, we have successfully completed family‐centered rounds using the teleconferencing platform zoom in 13 infants. Verbal feedback received from the parents (both parents, especially the father) were very encouraging as all of them found this program useful. The providers in the unit had a general feeling that it not only improved the satisfaction of the parents but also allayed some anxiety in them, especially involving the father.

Discussion: A video based teleconferencing platform was successfully utilized during the restrictions from hospital policy created by the pandemic. We believe that the successful implementation of this new program has future implications. Usually, fathers are still working when their infants are admitted to the NICU. A video teleconferencing platform can be offered to the working fathers to stay connected and involved in the care of their infants. This may improve satisfaction and reduce stress in fathers who are often not able to get involved to the extent they would like.

Reference: Noergaard B, Ammentorp J, Garne E, Fenger‐Gron J, Kofoed PE. Fathers’ stress in a neonatal intensive care unit. Adv Neonatal Care. 2018;18(5):413‐22.

Presenting Author e‐mail: anirudhdas26@gmail.com

67. Post‐Discharge Intervention for Stroke Caregivers: Protocol Description of the Randomized Controlled Trial

Avi Lamba¹, Jennifer H. LeLaurin, MPH^2,3, Nathaniel D. Eliazar‐Macke, RN², Magda K. Schmitzberger, MPH², I. Magaly Freytes, PhD^2,4, W. Bruce Vogel, PhD^2,3; Charles E. Levy, MD^5,6; Angelina S. Klanchar, RN⁷, Rebecca J. Beyth, MD, MSc^4,8, Ronald I. Shorr, MD, MS⁴, Constance R. Uphold, PhD, ARNP, FAAN^2,4,9, Stuti Dang, MD, MPH^{10, 11}

¹Flint Hill School, Oakton, Virginia, USA; ²North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA; ³Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA; ⁴Geriatric Research Education and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA; ⁵Physical Medicine and Rehabilitation Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA; ⁶Department of Occupational Therapy and Center for Arts in Medicine, University of Florida, Gainesville, Florida, USA; ⁷James A. Haley Veterans Hospital, Tampa, Florida, USA; ⁸Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, Florida, USA; ⁹Department of Aging and Geriatric Research, College of Medicine, University of Florida, Gainesville, Florida, USA; ¹⁰ University of Miami Miller School of Medicine Miami Veterans Affairs Healthcare System and ¹¹Willy Valencia‐Rodrigo, Florida International University, Miami Veterans Affairs Healthcare System

Background: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Caregivers usually have unmet needs involving the following categories: information, behaviors, physical care, and personal response to caregiving. Discharge planning and follow‐up home training with caregivers is particularly important because caregivers are most at risk for depression at the time of their survivors’ stroke and the immediate period thereafter. Follow‐up home support and problem‐solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem‐solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically.

Methods: The objective of this study is to test a problem‐solving intervention for stroke caregivers that can be delivered over the telephone during the patient’s transitional care period (time which the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. The design is a two‐arm parallel randomized clinical trial with repeated measures that uses mixed methods. We will enroll 240 caregivers from 8 Veterans Affairs medical centers. Participants randomized into the intervention arm receive a modified problem‐solving intervention that uses telephone and Web‐based support and training with interactive modules, factsheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers’ Understanding and Empowerment (RESCUE) Caregiver website.

Results: The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers’ burden, knowledge, positive aspects of caregiving, self‐efficacy, perceived stress, health‐related quality of life, and satisfaction with care and changes in stroke survivors’ functional abilities and healthcare utilization. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021.

Discussion: This is the first known study to test a transitional care and messaging center educational intervention combined with online training and application of the problem‐solving approach to improve the quality of caregiving and the recovery of patients post‐stroke, to enable them to remain at home. Other outcomes will be an updated, stroke caregiver website and an evidence‐based intervention (transitional care and online training and messaging between providers and caregivers) that can be transportable to other sites and used as a model to improve caregiving of patients with other chronic diseases.

Presenting Author e‐mail: Alamba@flinthill.com

69. Virtual Family‐Centered Rounds in the Neonatal Intensive Care Unit: A Pilot Trial

Jaskiran Ranu MD, Jennifer Rosenthal, MD, Kristin Hoffman, MD, Hadley SauersFord, MPH, CCRP, Jacob Williams, BA

UC Davis, Sacramento, California, USA

Background: Family Centered Rounds (FCR) are multidisciplinary bedside rounds that require active engagement from the family and are standard of care in pediatrics. Often times, due to distance, work and family obligations, parents are unable to attend FCR in the Neonatal Intensive Care Unit (NICU). The objective of this pilot trial to test the feasibility, acceptability and potential impact of conducting a trial comparing virtual FCR (vFCR) to standard bedside rounds.

Methods: This pilot trial is a two‐armed randomized control trial of hospitalized infants in the NICU. Infants are randomized to participate in vFCR (intervention) or standard bedside rounds (control). Feasibility is measured by intervention uptake, technical issues, intervention burden and survey response rates. Acceptability data is collected from interviews with families, nurses, and physicians. Exploratory outcomes include parent attendance and experience, length of stay, breastfeeding at discharge and adverse events. We will calculate proportions/means with a 95%CI.

Results: We have completed 2 out of 5 months of delivering the intervention. 33 infants have been enrolled in the study. Of the 21 infants randomized to the intervention arm, 12 were successfully recruited and 10 used vFCR at least once (83%). We have completed 79 vFCR encounters to date. Among the 79 encounters, 74 had no technical issues (94%). Survey response rate at discharge has been 58%. We have completed 3 qualitative interviews with families and are continuing interviews with families, nurses and physicians. Exploratory outcomes will be evaluated at the end of the study period.

Discussion: We have successfully delivered the intervention of vFCR in the NICU. With data collection ongoing, we are on target to achieve our enrollment of 90 patients (60 intervention, 30 control). This pilot trial is not powered to determine the benefit of vFCR versus standard of care, as that effectiveness question will be answered in a future trial.

Presenting Author e‐mail: jkranu@ucdavis.edu

72. Development of the Continuous Virtual Monitoring (CVM) Program at the Medical University of South Carolina (MUSC)

Emily Warr, MSN, Dee Ford, MD, MSCR, Kathryn King, MD, MHS, Kit Simpson, DrPH, Rebecca Beeks, MHA, Morgan Sires, Jillian Harvey, MPH, PhD, Parker Rhoden, MHA

Department of Healthcare Leadership & Management, Department of Health Sciences and Research, College of Health Professions, Department of Pediatrics, Center for Telehealth, and Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA

Background: Acute‐care inpatient falls have been, and continue to be, a major cost and quality issue in US hospitals. MUSC Health developed the CVM program to improve patient care and reduce sitter costs.

Methods: Two inpatient units were selected based on high fall rates to participate in the CVM pilot program. Program data and electronic medical record data were examined to assess the relationship between CVM implementation and falls.

Results: For the 2 pilot units, there was a substantial decrease in sustained falls over two years (unit A: 35%; unit B: 57%). This decrease equated in a fall cost avoidance of $280,000 for the 2 pilot units.

Discussion: CVM is a promising approach to improving patient safety and reducing cost. The program has potential use in behavioral monitoring and in reducing risk to healthcare providers during COVID‐19, while conserving PPE.

Presenting Author e‐mail: rhoden@musc.edu

73. Are Videoconferenced Mental and Behavioral Health Services Just as Good as In‐Person? A Meta‐Analysis of a Fast‐Growing Practice

Ashley B, Batastini PhD¹, Peter Paprzycki, PhD¹, Ashley C. T. Jones, MS², Nina MacLean, PhD³

¹Mississippi Center for Clinical and Translational Research, City, Mississippi, USA; ²University of Southern Mississippi, City, Mississippi, US; and 3Michigan Department of Health & Human Services, City, Michigan, USA

Background: Although various forms of remote and mobile services have begun to infiltrate the practice of psychology and psychiatry, the use of videoconferencing technology (VCT) has increased rapidly over the past decade, particularly in the wake of COVID‐19. With this, an increasing number of studies have examined the efficacy of this modality compared to in‐person intervention and assessment of mental and behavioral health concerns. The majority of existing studies have examined the success of VCT in the treatment of specific disorders, such as anxiety disorders, substance use, depression, and eating disorders. Other studies have focused on using VCT with special populations for whom the gap between service need and availability is especially wide or for specific types of services. In this study, a series of meta‐analyses were conducted using 44 empirical studies published over the past two decades that included variety of populations and clinical settings.

Methods: To be included in this meta‐analysis, studies had to (1) be published in English, (2) evaluate a mental health (i.e., psychological or psychiatric) service (i.e., therapy/counseling, assessment), (3) use a telecommunication service delivery system that transmitted live audio and visual information simultaneously, (4) use a between‐groups comparison design, and (5) report sufficient information to allow for a calculation of effect size estimates. When data were insufficiently described in a published report, the study’s corresponding author was contacted in an attempt to ascertain needed details. Studies with only within‐subjects designs (i.e. pre‐post telehealth, waitlist control) or that examined a nonmental health service (e.g., physical health services) were excluded from this review. Keywords related to “telehealth,” “telemedicine,” “telepsychology,” “telemental health,” and “telepsychiatry” were entered into approximately 38 electronic databases and internet search engines (e.g., PsycINFO, Medline, Google Scholar, PsycCRITIQUES, and Science &Technology Collection). Initially, a total of 504 related articles were identified for further review. Articles determined to meet inclusionary criteria were double coded.

Results: All statistical outcomes were coded in such a way that a positive effect size always favored the in‐person group and negative effect sizes favored the remote group. For intervention outcomes, both a conventional analysis using R metafor package and a three‐level Hierarchical Linear Model (HLM3) using R metaSEM were used. An HLM3 was used to evaluate the variance components of client sampling as well as the outcome‐ and study‐levels. Moderator, outlier, and publication bias analyses were also conducted. For intervention outcomes in the conventional analysis, the overall effect size for the estimated model was not statistically significant, Hedges’ g = 0.02, 95% CIs [‐0.10, 0.14], (SE = 0.061), p = 0.744, indicating no aggregate difference between outcomes associated with videoconference‐delivered interventions and those associated with in‐person interventions. The overall effect size estimated by the HLM3 model was also not statistically significant, Hedges’ g = 0.01, 95% CIs [‐0.09, 0.11], (SE = 0.052), p = 0.881. To account for interdependency between outcomes within studies assessing reliability coefficients, an HLM3 was applied. Results again were non‐ significant, Hedges’ g = 0.13, 95% CIs [‐0.00, 0.26], (SE = 0.07), p = 0.059.

Discussion: Overall, findings suggested that VCT and in‐person interventions produced similar changes from pre‐to post‐intervention (most of which focused on reductions in mental health symptomology using client self‐report instruments) and assessments conducted via VCT yielded similar measurement scores as in‐person assessment. Both the conventional analysis and HLM3 approach revealed that the intervention site may matter to some extent given that VCT interventions produced better outcomes within medical settings (which included VA hospitals) than in‐person interventions. Despite these promising findings, several limitations in the current literature base were revealed. Most concerning was the relatively limited number of randomized controlled trials and the inconsistent (and often incomplete) reporting of methodological features and results. Recommendations for reporting the findings of telemental health research will also be provided.

Presenting Author e‐mail: ashley.batastini@usm.edu

74. Utilizing Emergency Medical Technicians as Telehealth Facilitators in Addressing Changes in Condition for Home‐based Primary Care Patients

A. Camille McBride MPH, Jill Slaboda, PhD, Liane Wardlow, PhD, Michael Kurliand, MS RN, Karen A. Abrashkin, MD

Background: Home‐based primary care (HBPC) provides interdisciplinary in‐home medical care to medically complex patients who suffer from chronic conditions and/or functional or cognitive impairments. The HBPC aims to prevent unnecessary hospitalizations, aligning with patient and caregiver goals of receiving support, diagnostics, and treatment at home. HBPC providers often respond to unpredictable changes in condition, which cause operational challenges to efficiency since they require altering providers’ schedules and routes. The goal of this investigation was to assess if and how telehealth could be used to address operational challenges and enable providers to care for more patients in a day. We piloted a telehealth model that utilized Emergency Medical Technicians (EMT) as telehealth facilitators to help our patients connect with their remote HBPC providers in efforts to increase access to care for homebound senior patients—a model we called the Mobile Telemedicine Technician (MTT) Model.

Methods: The MTT model was implemented one day a week (Monday) to assist the HBPC provider in addressing patient issues that arose over the weekend or the week prior. Trained EMTs, were deployed to make home visits—to patients the provider identified—where they performed assessments (vitals and physical exams) and used secured two‐way video conference to connect patients to their clinic‐based primary care provider. All clinical decisions remained with the HBPC provider. After visits, patients or caregivers completed satisfaction surveys which the research team recorded on REDCap.

Results: The pilot began in July 2019 and from inception to February 2020, 253 MTT visits were conducted. Using the MTT model doubled the number of visits per provider performed each day as compared to the traditional HBPC model (10 visits with MTT versus 5 visits without). Common and appropriate reasons for an MTT visit included new skin condition assessments, medication changes, altered mental status and follow‐ups due to treatment plan changes over a weekend. MTTs spent approximately 33 minutes with patients and providers spent 9.4 minutes per visit on the telehealth visit (excluding documentation and additional care coordination), on average. Patient/caregiver survey response rate was 45%. Approximately 96.5% of patients or caregivers were satisfied with management of their medical issue with the MTT model and 80% would be happy to use MTT visits in the future. Only 19% reported that they would have preferred to wait for a regular provider visit even if it meant a later appointment date. Preliminary results from the first 100 visits found that 6% of MTT visits resulted in an EMS response for transport to the hospital—the outcome of the vast majority of visits was a routine in‐person (61%) or telephone visit (16%).

Discussion: There is a need for HBPC programs to seek ways to optimize operations and increase access to care for vulnerable home‐bound seniors. This investigation found that utilizing EMTs in a telehealth facilitated model to address medical issues of homebound seniors within a HBPC practice allowed physicians to effectively care for twice as many seniors per day as compared to traditional HBPC models. Furthermore, survey data suggested this model has high rates of patient and caregiver satisfaction. Further studies will be conducted to assess cost of care delivery with this new model of care.

Presenting Author e‐mail: amcbride1@northwell.edu

76. Variation in Telemedicine Adoption in a Pediatric Primary Care Network during COVID‐19 Pandemic

Kelsey Schweiberger, MD¹, Alejandro Hoberman, MD^1,2, Jennifer Iagnemma, DNP, RN², Pamela Schoemer, MD², Joseph Squire, RN, BSN², Jill Taormina, RN, BSN², David Wolfson, MD², Kristin N. Ray, MD, MS^1,2

¹Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA and ²UPMC Children’s Community Pediatrics, Wexford, Pennsylvania, USA

Background: The COVID‐19 global pandemic led to rapid changes in payment and regulations surrounding telehealth which allowed for telehealth integration into primary care pediatrics. Using data from a large pediatric primary care network, we aimed to examine the association of practice‐level telemedicine adoption with reasons for telemedicine visits within each practice and receipt of in‐ person visits by children cared for by each practice.

Methods: We analyzed electronic health record data from 45 practices caring for 315,000 children within a pediatric primary care network from 3/18/2020 to 5/2/2020. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, and high) per 1,000 patients during a two‐week period (4/17‐5/2/2020). This time frame was chosen so that practices were stratified by rates of telemedicine use one month into our regions stay‐at‐home order, when telemedicine use rates appeared to have stabilized after initial adoption. By practice tertile, we compared (1) practice characteristics using Kruskal‐Wallis tests, (2) distribution of telemedicine visit diagnoses using chi‐ squared tests, and (3) patient in‐person visit rates to clinic, urgent care and emergency department using Kruskal‐wallis tests.

Results: Across 45 primary care pediatric practices, practice telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. High telemedicine use practices had more physicians in the practice (median 4 vs 3, p = 0.04), but similar patient panel sizes, and similar representation of Medicaid versus commercially insured patients in their practices. Across all practice tertiles, the most common visit diagnoses were mental health, skin and soft tissue, and respiratory diagnoses. However, for practices in the high telemedicine use tertile, these diagnoses comprised a smaller percentage of overall telemedicine visit diagnoses. Compared to low tertile practices, high tertile practices had fewer in‐person clinic visits (10 versus 16 visits per 1000 patients per week, p = 0.005). When considering telemedicine and in‐person clinic visits together, this total primary care visit volume summed to 55% of 2019 visit volume for high telemedicine use practices, compared to 45% of 2019 visit low telemedicine use practices. Visits to urgent care during the pandemic were similar across tertiles (p = 0.1), although high tertile practices had slightly more ED visits (2 versus 1 ED visits per 1000 children per week, p = 0.02).

Discussion: Telemedicine use varied across pediatric primary care practices within a pediatric primary care network during the COVID‐19 pandemic. Practices with higher telemedicine use tended to have more physician providers, but other practice characteristics were similar across tertiles. Telemedicine visit diagnoses at practices with higher telemedicine adoption reflected a more varied telemedicine practice in comparison to practices in the low tertile. Practices that used telemedicine at higher rates had fewer in‐person office visits than practices with lower telemedicine use. Accounting for both telemedicine and in‐person primary care visits, practices with higher telemedicine use were able to sustain visit volume closer to pre‐pandemic rates than practices with lower telemedicine use. Overall, practices with higher telemedicine use delivered more varied care via telemedicine and had contact with patients that more closely resembled pre‐pandemic rates

Presenting Author e‐mail: schweibergerka@upmc.edu

77. One‐Size‐Fits‐All: Formal Telemedicine Provider Training in Response to the Widespread Need to Scale

Dana A. Schinasi MD, M. Katie Bohling, MBA Rebecca Stephen, MD MS Aric Shimek, BSN RN CPN Marisa Furney, MHA

Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA

Background: There is widespread debate on the necessity of standardized, consistent formal provider training in telemedicine. A formalized training program addresses previously cited barriers to provider adoption and engagement in telemedicine and assures a level of competence for independent practice. We previously described a blended model training program, customizable according to provider specialty and discipline; its successful completion is a requirement for Telemedicine Privileges through our Medical Staff Office (MSO). DTC telemedicine had not been widely utilized to date in the context of unfavorable telemedicine legislation in Illinois. COVID‐19 necessitated widespread rapid deployment of a telemedicine curriculum to enable competent independent practice of DTC telemedicine. We describe the development and implementation of our multi and interdisciplinary telemedicine provider training program to enable the rapid and massive scaling of DTC telemedicine at our institution.

Methods: Our institution is an independent quaternary academic children’s hospital located in an urban environment. In 2019, > 650,000 ambulatory visits were conducted, fewer than 0.5% of which were via telemedicine. The previously existing customizable Telemedicine Provider Training curriculum was pared down to a 1‐hour session delivered synchronously and covered the following foundational components: background (definitions, local context), legal and risk considerations, workflows, clinical considerations (physical examination, charting requirements), virtual presence, technology. Providers were then directed to the Telemedicine Virtual Handbook, a custom resource with further detail on topics introduced in the structured training, available via a password‐protected site. In‐person training was offered in the hospital conference center where in‐person attendance was capped to ensure compliance with safe social distancing recommendations. A virtual attendance option was available for those who were unable to safely attend in‐person. All providers who see patients primarily were required to attend a session; those in supporting roles (e.g. nursing staff, child life specialists) were welcome but not required.

Results: We conducted 35 sessions and trained 1,070 providers over 12 weeks (27 sessions, 791 providers in the first 4 weeks). Those in attendance included a mix of physicians, APPs, psychologists, social workers, clinical nutritionists, speech therapists, occupational therapists, case managers, and more. As trainees re‐joined the clinical workforce, they, too, received training. In total, 595 providers received Disaster Telemedicine Privileges through the MSO, which were immediately released, lasting 120 days. Additional resources were created and available through the Telemedicine Virtual Handbook are housed in specific toolkits. The Provider Toolkit includes EHR guides and tip sheets, physical examination (PE) tip sheet, library of 7 videos developed in‐house on various telemedicine PE components, provider checklist, accessing interpreting services, as well as sample materials (e.g. patient/family pre‐visit letter). Additional resources housed on the Virtual Handbook include Technical, Scheduling, Clinical, and Webside Manner Toolkits, as well as a repository for resources for program evaluation and QI.

Discussion: Telemedicine training is necessary for consistent competent practice of telemedicine. We describe a training process that can be easily replicated and rapidly deployed to providers of DTC telemedicine across disciplines and specialties. Combining a mandatory and brief synchronous provider training session with a growing repository of online resources creates a foundation of consistent practice, while also allowing for more detailed and individualized resources that can be accessed on demand. Standardized telemedicine training followed by ongoing professional practice evaluation (OPPE) allow for institutions to ensure consistent and competent practice of telemedicine.

Presenting Author e‐mail: dschinasi@luriechidlrens.org

78. Evaluating Disparities in Access to Telehealth at a Pediatric Gastroenterology Clinic During a Pandemic: A Preliminary Analysis

Abigail Russi, MD, PhD¹, Peter R. Farrell, MD, MS^2,3, Lindsey Hornung, MS⁴ Kaitlin G. Whaley, MD^2,3, Anita N. Shah, DO, MPH^3,5, Andrew F. Beck MD, MPH^3,6, Leslie Farrell, MD^3,5, Cole Brokamp, PhD⁴, Carrie Romano, DNP, RN², Jen Hardy, BA, CCDM², Jennifer Hellmann, MD^2,3

¹Department of Pediatrics, ²Division of Gastroenterology, Hepatology and Nutrition, ⁴Division of Biostatistics and Epidemiology, ⁵Division of Hospital Medicine, and ⁶Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA; and ³Department of Pediatrics (DOP), University of Cincinnati College of Medicine, Cincinnati, Ohio, USA

Background: The novel coronavirus (SARS‐CoV‐2) pandemic has challenged healthcare systems to adapt in many ways, including the rapid adoption of telehealth. Data are emerging that demonstrate significant disparities in morbidity and mortality by race, ethnicity, and socioeconomic status. There is mounting evidence that indirect effects of the pandemic are also disproportionally affecting racial/ethnic minorities and members of lower socioeconomic classes through unemployment, school and daycare closings, and difficulties with social distancing. Disproportionate access to telehealth may lead to disparities in how and when patients return to care. The purpose of our study was to explore the relationship between the use of new telehealth services and a range of sociodemographic variables of patients seeking care within the Division of Gastroenterology, Hepatology and Nutrition (GI) at Cincinnati Children’s Hospital Medical Center (CCHMC).

Methods: Retrospective review of children seen by CCHMC GI between 1/1/20‐5/15/20. Non‐residents of Ohio or Kentucky were excluded. We compared sociodemographic variables across 3 samples: (1) Baseline: Patients seen in person for a clinic visit between 1/1/20‐3/13/20 when clinics were closed. This is the reference population; (2) Telehealth: All patients who completed a telehealth visit between 3/16/20‐5/15/20; and (3) Cancelled: (a) Cancelled with Telehealth: Patients who had an in‐person clinic visit cancelled and rescheduled for a telehealth visit between 3/16/20‐5/15/20 and (b) Cancelled with No Telehealth: Patients who were scheduled for a clinic visit between 3/16/20‐ 5/15/20 but were cancelled and had no telehealth visit scheduled. Sociodemographic variables assessed across groups were age, sex, race, ethnicity, language, and socioeconomic deprivation. Community deprivation was approximated using an index derived from address‐linked data incorporating 6 unique census tract‐level factors. It is measured on a scale from 0 to 1, with higher values indicating more deprivation. Variables were compared across groups using Wilcoxon‐Mann‐Whitney tests for continuous variables and Chi‐square or Fisher’s exact tests for categorical variables.

Results: There were no differences between the Baseline Sample (n = 4,326) and Cancelled Sample (n = 3,200) based on age, sex, race, ethnicity or deprivation index. The Telehealth Sample (n = 810) had a significantly smaller proportion of patients who were Hispanic (3.5% vs 6.1%, p = 0.003) and a higher proportion of English‐speaking families (99.4% vs 95.8%, p < 0.0001). The median deprivation index was significantly lower in the Telehealth Sample (0.31 vs 0.32 p = 0.002) when compared to the Baseline Sample. The Telehealth Sample included patients originally scheduled for a clinic visit and patients who were added to the schedule. To better determine the rate of conversion of clinic visits to telehealth visits, the Cancelled Sample was subdivided into patients that were scheduled for a telehealth visit and those who were not. There were fewer patients who were White/Caucasian (84% vs 88% p = 0.04), a higher proportion of patients who were Hispanic (6.3% vs 3.8%, p = 0.02), fewer English‐speaking patients (95.7% vs 99.3%, p < 0.0001) and there was a higher deprivation index (median 0.33 vs 0.31, p = 0.002) in the Cancelled with No Telehealth Sample (n = 2,611) versus the Cancelled with Telehealth Sample (n = 589).

Discussion: These data suggest that minority populations were less likely to participate in Telehealth within our division during the initial SARS‐CoV‐2 clinic shut down. We detected a statistical difference in deprivation indices; however, the magnitude of the difference is small and its clinical relevance is unclear. The fact that this is a retrospective review of only one division’s data is a limitation. While this analysis is preliminary and more extensive modeling is underway, these data provide an important early look into potential disparities that could emerge from adoption of telehealth. The next phase includes a subpopulation analysis based on common clinic diagnoses and examination of payor data. Understanding the disparities in access to telehealth is essential in order to address them as we continue to expand our use of telehealth and alternatives to in‐clinic visits. With no immediate end in sight to the pandemic, we suspect use of such technologies will only expand.

Presenting Author e‐mail: Abigail.Russi@cchmc.org

79. Attitudes and Perceptions of Telemedicine in Response to the COVID‐19 Pandemic: A Survey of Naïve Healthcare Providers

Dana A. Schinasi, MD, M. Katie Bohling, MBA, Carolyn C. Foster, MD, MSHS, Rebecca Stephen, MD MS, Kenny Kronforst, MD, MPH, Michelle L. Macy, MD M

Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA

Background: The COVID‐19 pandemic necessitated changes to healthcare delivery to ensure the safety of patients and providers. The national emergency loosened restrictions on provision of care and increased reimbursement, enabling widespread rapid deployment of telemedicine services in health care systems across the US. Illinois is one of a few remaining states without previously existing favorable legislation on telemedicine; in this context, there was a paucity of providers with telemedicine experience prior to the pandemic. We formally trained and onboarded > 1000 providers in telemedicine across various disciplines and specialties, the majority of which were largely naïve to the practice of telemedicine. We sought to better understand their attitudes and perceptions on telemedicine in general and with respect to its potential impact on care during a pandemic at two points in time: prior to onboarding, and three months following widespread expansion of telemedicine at our institution.

Methods: We conducted surveys of healthcare providers to assess attitudes and perceptions on telemedicine. Setting: An independent free‐standing quaternary academic children’s hospital located in an urban environment, with more than 1,600 physicians and allied health providers in 70 pediatric specialties. All providers who deliver care for patients at our institution, regardless of discipline or specialty, are required to undergo a synchronous Telemedicine Provider Training session prior to delivering care via video conferencing. Survey Development: We developed a brief online survey drawing from prior literature. We pilot tested the survey with five individuals on our telemedicine evaluation team and refined questions and response options based on their feedback. Survey Distribution: Baseline surveys were distributed at the point of training in telemedicine and 3 months after telemedicine had been deployed at our institution. Follow‐up surveys were distributed via email on July 8, 2020. Descriptive statistics for the pre‐survey were calculated. Pre and post comparisons will be conducted after follow‐up survey responses are collected.

Results: All 1,070 providers who signed up for a Telemedicine Provider Training session were sent a survey. Our response rate was 58% (617), and 26 were excluded (missing responses, not telemedicine‐naïve); data are reported on this resultant sample of 591 providers. The largest roles represented were pediatric subspecialties (35%), general pediatrics (16%), nursing (14%); other roles include psychiatry, surgery, PT, OT, speech therapy, physician assistant. Roughly 1/3 of respondents reported being in practice for  < 5 years (34%) or > 15 years (32%). Most (54%) anticipated it would be easy to incorporate telemedicine into their clinical practice, while 22% anticipated difficulty. Respondents expressed strong agreement with statements of anticipated telemedicine benefits in the pandemic response: decrease staff exposure (93%), reduce transmission to families (93%), conserve PPE (92%). 97% indicated concern about patient/family access. The majority (68%) of naïve providers anticipated continued use of telemedicine after the COVID‐19 response concludes. Results of the follow‐up survey will include changes in perceptions and attitudes, as well as factors that will have the greatest influence on continued use of telemedicine into the future.

Discussion: In response to COVID‐19, providers of heterogenous backgrounds, roles, and disciplines previously naïve to telemedicine anticipated telemedicine would be valuable in mitigating certain risks associated with the pandemic. Some providers anticipated challenges in integrating it into their practice and nearly all providers had at least some concern about families’ ability to access care that was dependent upon video conferencing. Findings from the follow‐up survey will allow us to highlight how training and clinical experience influence attitudes and perceptions of telemedicine as a new mode of care delivery for most providers in our institution. Additionally, we will compare pre and post responses within groups of providers and within disciplines. These findings will inform future efforts to better meet provider onboarding needs.

Presenting Author e‐mail: dschinasi@luriechildrens.org

81. Interprofessional Telehealth Education: Operationalizing Results from a Five‐Year Study

Ragan DuBose‐Morris, EdS, PhD

Center for Telehealth, Medical University of South Carolina, Charleston, South Carolina, USA

Background: Students participating in an interprofessional elective have demonstrated understanding of the application of telehealth as part of their current and future health care practice. An analysis of the students’ data yields insight into how effectively the learners are able to acquire knowledge and self‐ confidence with the subject matter in a semester course. These foundational experiences are essential in response to a global pandemic when coupled with specific training initiatives that enable students to quickly operationalize telehealth services with appropriate supervision. Similar applications of curriculum across GME programs also has resulted in significant knowledge gain while advancing clinical transitions within the ambulatory and inpatient settings. These findings demonstrate the universal need for formal telehealth education across degree programs in order to educate trainees, enable their participation in experiential learning and create new care teams to improve patient care.

Methods: In 2014, a group of academic health center faculty extended their knowledge of telehealth best practices through an interprofessional elective. Based off of Kern’s six‐step curriculum development model for medical education, the elective was piloted to address the growth of telehealth as a modality of healthcare delivery and the need to integrate curriculum into formal health professions programs. The curriculum sets the stage by explaining how the evolution of telehealth factors into changing models of care and is based on known factors, such as technical, legal and regulatory guidelines, but also challenges the students to frame their practice in terms of a team approach that is supported by health informatics. Pre‐post self‐assessment of knowledge results of categorical survey questions were explored using chi‐squared and Fishers exact test as appropriate. No significant differences were found between cohorts across time in either pre‐ or post‐assessments. Therefore, all pre‐responses were combined, as well as post‐course survey responses. The answers to the open‐ ended questions were analyzed using conventional content analysis to interpret the content of text through coding, systematic classification, and theme identification.

Results: Results from the pre‐and post‐survey of students have been consistent over the five years. While growth of telehealth technologies would imply that students have a higher level of self‐professed knowledge, competency and comfort related to telehealth and interprofessional practice, the data show that not to be the case as the change in pre‐test baseline scores is not statistically significant (p = 0.952). Students reflect clear growth in knowledge and confidence over the semester. In the pre‐ assessment tool, only 6% of students felt comfortable explaining three tele tools and post course 80% could. Similarly, when asked about comfort in determining “how telehealth improves patient access to specialists and mental health providers”, students’ ratings were predominantly neutral or negative on the pre‐test (77%) with overall positive ratings on the post‐test (95%). The researchers also conducted qualitative thematic counts on open‐ended responses. These counts reveled themes related to the students’ self‐perceived roles as providers which highlighted an increase in collaboration due to the interprofessional structure. Student quotes illustrate each of the primary themes including how the “course influenced their role as a professional.

Discussion: Even though telehealth is becoming more common, data shows no statistically significant changes in the students’ baseline knowledge. Results show not only an opportunity to advance the individual knowledge of trainees, but a larger movement to facilitate changes in practice towards population health goals. The focus of this training is made possible by the frameworks established by accrediting bodies and by the structures afforded institutions that serve as originators of specialty services. Competencies have begun to be developed and need to account for the necessity of virtual consultations. This requires integrated training. Similar levels of engagement have been seen in interventions for residents who plan to pay it forward and “use [the course] to train fellow physicians and support staff”. This model of developing telehealth champions through education addresses patients’ needs during a pandemic while also fostering opportunities to positively impact future health systems

Presenting Author e‐mail: duboser@musc.edu

82. Bending the Curve with Telehealth Nursing: A Novel Post‐Discharge Transitions of Care Program

Christina Olson, MD^1,2, Mark Brittan, MD, MPH^1,2, Susan Fisk, BSN, RN¹, Fidelity Dominguez, BSN, RN, CPEN¹, Kristen Hounsel, MS, RN, CCM, CCCTM, Sara Nickels PhD, MSW¹

¹Children’s Hospital Colorado, City, Colorado, USA and ² University of Colorado School of Medicine, Aurora, Colorado, USA

Background: Medically complex children have challenging hospital‐to‐home care transitions and incur high hospital utilization and costs. Problems occurring during transitions of care also lead to unplanned emergency use and readmission, further increasing the overall cost of their care. The evidence suggests that nurse visits can decrease unplanned health care utilization in this population, but these visits are limited by geography and resources. By offering telehealth‐based home nurse visits during the first 30 days after discharge, we aim to improve care transitions for medically‐complex pediatric patients and prevent unnecessary utilization after discharge. The first objectives are to build a robust model for tele‐nursing and identify and address health and social issues impacting post‐discharge care (which may or may not have been discovered during the hospitalization), with the ultimate objective being a reduction in emergency department (ED) visits and hospital readmissions.

Methods: Eligible patients, identified by an electronic medical record (EMR) registry, are those admitted at our academic children’s hospital with ≥1 home health order, length of stay > 7 days, ≥1 hospitalization in the prior 12 months, and assignment to a primary team participating in the project (rolling out to teams through 2020). When a patient nears discharge, the project nurse reaches out to the patient’s team, then meets the patient/ family at the bedside to establish a relationship. Families agreeing to enrollment are provided with guidance on accessing the telehealth system and a tele‐nurse appointment within 7 days after discharge is made. During this visit, the nurse verifies that patients/ families understand and are following the discharge plan of care and addresses any concerns or barriers related to social determinants of health that impact their ability to adhere to this plan. Outcomes tracked are: % of enrolled patients with an ED visit and/or readmission during the 30 days after discharge, % of eligible patients approached about project enrollment, % of enrolled patients with ≥1 telehealth encounter 30 days post‐discharge, and % of telehealth encounters in which a post‐ discharge problem is identified and addressed.

Results: Initial process mapping work resulted in the creation of a patient eligibility dashboard, a new documentation template to track project telehealth visits and their outcomes, a more efficient method for scheduling nurse telehealth visits, and a process for adding interpreters to video visits. In the first 5 months, 121 patients have been identified as meeting eligibility criteria and 40 patients have been enrolled from 12 primary medical, surgical and rehabilitation teams. 41 telehealth encounters have been completed (4 included presence of patients’ home health nurses), with 40% of these encounters resulting in identification and resolution of a post‐discharge problem. These problems have been diverse and include medication questions, symptom triage, follow‐up care coordination, and difficulty accessing community services or durable medical equipment recommended at discharge; several could have resulted in an ED visit or readmission if they had not been resolved in a timely manner. Next steps are data analysis to establish baseline 30‐day ED visit and readmission rates for this population, comparing this baseline against enrolled patient data, and iteratively fine‐tuning the model to facilitate expansion to more services.

Discussion: Although pediatrics accounts for lower costs than adult medicine, children with medical complexity are a major contributor to health care spending, and many of these patients visit the ED and/or are readmitted after discharge for problems falling between the cracks of the existing system. Preliminary data from this project demonstrate that post‐discharge nurse telehealth visits are a valuable method of bridging this gap by bringing to light challenges not apparent during the hospitalization and closing the loop on services recommended during the inpatient stay. Identified key factors include establishment of a nurse‐family relationship before discharge, direct access to the EMR’s discharge plan, collaboration with case managers and follow‐up providers/ nurses, and the Enhanced Nurse Licensure Compact allowing cross‐state telehealth. Separately, this project’s process work was critical when rapid expansion of telehealth nursing was needed for other patients during the COVID‐19 pandemic.

Presenting Author e‐mail: christina.olson@childrenscolorado.org

83. Using the ECHO Model to Address the Needs of Healthcare Professionals During an Emerging Threat

Jessica Leffelman¹, Shannon Limjuco, MPH¹, Henry H. Bernstein, DO, FAAP², Laurence E. Flint, MD, FAAP³, Steve Caddle, MD, MPH, FAAP⁴, Trisha Calabrese, MPH¹

¹American Academy of Pediatrics, City, State, USA; ²Northwell Health Hospital, New Hyde Park, New York, USA; ³Newton Medical Center; City, State, USA; and ⁴Columbia University Irving Medical Center, New York, New York, USA

Background: Due to the rapid increase of COVID‐19 cases in the United states between late February and early March 2020, the American Academy of Pediatrics (AAP) identified the need for a rapid public health response and quickly launched the COVID‐19 ECHO (Extension for Community Healthcare Outcomes) TM. Project ECHO is a tele‐mentoring program designed to create communities of learners by bringing together health care providers and experts in topical areas using didactic and case‐based presentations, fostering an “all teach, all learn” approach. Using basic, widely available videoconferencing technology, clinical management tools, and case‐based learning, health care providers develop knowledge and self‐efficacy on diseases, conditions, and/or processes. This session will outline the innovative approach used in the AAP COVID‐19 ECHO to address the needs of healthcare providers regarding the emerging threat of a global pandemic.

Methods: The AAP rapidly developed the AAP COVID‐19 ECHO program for pediatric primary care providers to increase clinical knowledge, comfort and competence regarding emergency readiness and response through the lens of COVID‐19. Within 20 days, the AAP obtained administrative approvals, developed programmatic materials, and recruited faculty and participants to launch the program. Faculty were identified through AAP Councils and were trained on the ECHO model. Participants were recruited through AAP membership listservs and were invited to attend 1‐hour sessions twice a month. Curriculum were developed with input from faculty and specialists identified by AAP Councils and Sections. Of importance is adaptability and flexibility of the program to meet the real‐time needs of participants. After each session, participants are asked to complete a survey. The survey examines participant characteristics, evaluates the session, and identifies upcoming topics of interest for participants. The project team uses information from the survey to identify topics and develop the curriculum schedule of the ECHO in real‐time. At the conclusion, a retrospective program survey will be administered, and a focus group will be conducted to evaluate the program.

Results: There were 1,770 healthcare providers that completed an application for the AAP COVID‐19 ECHO. Of them, 89% were physicians and 11% were healthcare professionals with other training. To meet the scheduling needs of the majority of the registrants, 27 cohorts were created and a range of 30 – 50 healthcare providers self‐signed up to join each cohort. (Project ECHO sessions are purposefully kept small to encourage active participation and build peer support over time). As of July 2020, there have been 997 unique individuals that have attended at least 1 ECHO session. The average number of participants per session is 473. On average 70 individuals completed the post session survey which evaluates the ECHO session’s content and instruction as well as provides a space for the participants to identify future topics. Of those that respond,99.7% have rated the sessions ability to deliver balanced and objective evidence‐based content Good to Excellent. A retrospective survey will be administered upon program conclusion in August 2020 to evaluate program impact.

Discussion: This project demonstrates that the ECHO model is an effective and efficient way to disseminate information and provide support for healthcare professionals in real‐time during a global public health threat. Using the ECHO model offers advantages over traditional training methods and can be adapted for other healthcare crises to educate professionals in real‐time.

Presenting Author e‐mail: jleffelman@aap.org

84. Timing of Telehealth Neonatology Consults on Newborn Resuscitation Quality and Transfer Rates in Community and Rural Hospitals

Lory J. Maddox, MSN, MBA, RN^1,2, Janice Morse, RN, PhD, FAAN², Gwen Latendress, PhD, CNM, FACNM², Wilson, PhD, MStat², Stephen Minton, MD¹, Jordan Albritton, PhD, MPH¹

¹Intermountain Healthcare, Salt Lake City, Utah, USA and ²College of Nursing, University of Utah, Salt Lake City, Utah, USA

Background: Synchronous video telehealth programs supporting time‐sensitive newborn resuscitations and consultation have found improved resuscitation quality rating scores and reduction in transfer rates. This study describes neonatology consults practice patterns before and after telehealth implementation, and the timing of initial neonatologist consult. We also compare resuscitation quality rating scores between usual care (UC) in both pre‐ and post‐telehealth implementation to video‐ assisted resuscitation (VAR) neonatologists’ arrival time to resuscitation on video, and the effect of the resuscitation quality on transfers to a tertiary or quaternary NICU. We hypothesize that VAR is associated with improved resuscitation quality. We also hypothesize that higher resuscitation quality lowers the risk of transfer for neonates born in hospitals without neonatology expertise.

Methods: From a population of 75,284 newborns born between 2013 and 2017 in 16 birthing hospitals, we obtained billing codes and clinical event data indicating resuscitation, documented telehealth notes, or a transfer to a tertiary or quaternary NICU for a cohort of 2,762 high‐risk newborns eligible to remain at the birthing facility. From this proposed sample, three sites were excluded for unusually low telehealth utilization rates leaving 13 sites with a cohort of 1,577 cases. Additional exclusion criteria included newborns who did not need any NRP interventions or were transferred because care was outside the birthing facility’s scope. Propensity score matching between UC and VAR cases is used to reduce bias based on the likelihood of having a neonatology consult. Maternal and newborn characteristics are used for propensity matching. Logistic regression is used to determine if neonatology presence during resuscitation improves resuscitation quality and reduces odds of the transfer to a quaternary or tertiary NICU.

Results: A neonatology consult was requested in 70.4% of all cases, with no NRP interventions needed, 23.0% in the UC group, and 35.1% in the telehealth consult group. Transfers from the UC consult group’s birth facility is 95.3% and 45.7% in the telehealth group. Preliminary frequency distributions suggest that video‐assisted resuscitation (VAR) may be impacting resuscitation quality. When VAR is initiated, before and at‐birth, the quality of resuscitation is higher than UC and VAR initiated after birth. Comparisons between UC and VAR prior‐to and at—birth are lower for cardiac compressions, 7.3% v. 2.3%, epinephrine administration, 2.7% v. 0.0%, and intubation on the first attempt, 28.8% v. 18.2%. Recorded time‐to temperature and blood sugar recorded are similar between UC and VAR before and at‐birth groups, but lowest in the VAR initiated after birth group. Blood gas recorded within 40 minutes is highest in VAR after‐birth group (94.2%), when compared to VAR prior‐to, and at‐birth (72.7%), then UC (63.9%). Additionally, newborns discharged with supplementary oxygen are the lowest, 15.9%, when VAR is initiated before or at‐birth, 17.3% for VAR after birth, and UC, 23.3%.

Discussion: This telehealth neonatology program emphasized notifying the neonatologist before birth, allowing time for video connection, the onsite team to brief the neonatologists, reviewing post‐delivery interventions, and identifying, locating, and testing anticipated equipment needed for the resuscitation. This emphasis on pre‐birth notification may account for the increased frequency of neonatologists attending a birth when no NRP interventions were required. Gains in improved resuscitation quality scores, reduced transfer rates, and fewer newborns requiring oxygen at discharge are most significant when VAR is initiated before and at‐birth. When making a staffing proposal for a neonatology telehealth consult and resuscitation program, allowances must be made for standby time. The availability and timing of VAR impact population health, one baby at a time.

Primary Author e‐mail: lory.maddox@imail.org

85. Emergency Medical Technicians’ Perspectives on a Novel Telehealth Care Delivery Model Serving Homebound Older Adults

A. Camille McBride MPH, Olushola Latus‐Olaifa, Jill Slaboda, PhD, Amparo Abel‐Bey, MPH, Karen A Abrashkin, MD

Northwell University, Great Neck, New York, USA

Background: Older homebound adults with multiple chronic medical conditions often have difficulty accessing medical services in the home, leading to unwanted and unnecessary hospitalizations. Home‐based medical services can support individuals aging in place, but these services cannot meet the current demand in the US, and as the number of older adults in the US grows this problem will be further magnified. Recognizing a need to increase services across our service area and that many homebound older individuals lack resources to participate in telehealth practices, our program implemented a facilitated telehealth model utilizing Emergency Medical Technicians (EMTs) as telehealth presenters, who visited patients in their homes to conduct physical exams and connect them to their remote physician. In this study, we examined the participating EMTs’ perspective of using telehealth to deliver care in the home and investigated their experience and perception of operating in this expanded clinical role.

Methods: Data was collected from the four participating EMTs using a satisfaction survey administered monthly and a semi‐structured focus group. The survey was developed to collect feedback on satisfaction with their experience as well as the usability and reliability of the telehealth platform. The focus groups focused on understanding their experience in the MTT program, advantages and disadvantages of the program, ways to improve and expand, and potential career opportunities provided by the program. The satisfaction surveys were analyzed using descriptive statistics that identified frequency and percentage response distributions. A deductive thematic analysis approach was used to analyze the focus group transcripts. The analysis followed a process of developing codes, coding the transcripts, then generating themes based on identifying patterns in the codes.

Results: Response rate for the satisfaction surveys were 100% each month. Seventy‐nine percent strongly agreed and 17% agreed that they were satisfied with and learned a lot from their experience. The MTTs’ sentiments from the focus groups were overwhelmingly positive when discussing the structure of the program and their responsibilities as physician extenders. The results from the EMT surveys and focus groups illustrate continued satisfaction and support of this telehealth model. The results also elucidate the many benefits to EMT well‐being and education as well as the desire for expansion of this kind of model because of the potential additional career options it can provide. Considerations for implementing models utilizing EMTs included providing a more livable wage, providing flexible and consistent scheduling, and low to no cost additional training opportunities for clinical care and content.

Discussion: This facilitated telehealth model was viewed as a benefit to EMTs’ career outlook, provided an opportunity for more clinical education for EMTs, and was a beneficial use case for utilizing telehealth to increase medical access to homebound patients without compromising quality of care. However, models deploying EMTs in nontraditional roles have limited capacity to expand under current reimbursement structures. Regulatory and commercial reimbursement practice changes are necessary to allow for the possibility of new telehealth delivery models

Presenting Author e‐mail: amcbride1@northwell.edu

87. Considerations for Equity in COVID‐19 Pediatric Telemedicine Delivery

Oluwaseun Oke, MBBS, MPH, Molly Beyer, MS, MPH, CPH, Oluwaseun Oke, MBBS, MPH, DeAngalo Nesby, MBA, MSHA, Carlos Gomez, Stormee Williams, MD, Brian Robertson, PhD, MPH, CSSBB

Children’s Health and UT School of Public Health, Dallas, Texas, USA

Background: The advent of COVID‐19 brought substantial changes to healthcare delivery, including a rapid and dramatic shift from traditional face‐to‐face interactions to the virtual medium of telemedicine. While telemedicine has been able to increase access to care for many remote patients, there are still opportunities for improvement as inequities across racial and ethnic groups persist. A recent study conducted in Dallas, Texas showed approximately 25 percent of all family households in Dallas did not have access to a broadband subscription service (Commit Partnerships 2020). The infrastructure needed (e.g., computer, smartphone, broadband access) to participate in a virtual health visit can limit the ability to access telemedicine services. Additionally, challenges regarding the perception of telemedicine (e.g., privacy practices, accuracy of diagnosis, availability of services to uninsured or undocumented) and its ability to accommodate patients and caregivers with limited English proficiency.

Methods: A retrospective cross‐sectional study was conducted on patients who attended the outpatient clinics of Children Health System of Texas at two time periods: March to May 2019 (Pre COVID‐19 period) and March to May 2020 (COVID‐19 period). A bivariate analysis (chi‐square test and independent sample t‐tests) was conducted to compare the sociodemographic characteristics of patients seen between the 2 time periods and logistic regression analysis to estimate the odds ratio (OR) of utilizing telehealth services.

Results: A total of 70,274 patients had 98,222 office visits within the 2 time periods of which 65% occurred Pre‐COVID‐19 and 35% during COVID‐19. Telehealth visits comprises 40% of total visits seen during the COVID‐19 period and none occurred during the Pre COVID‐19 time period. There was a statistically significant difference in the race/ethnicity, language and age of patients seen between the 2 time periods (p‐value < 0.05). Specifically, among patients with clinic visits in COVID‐19 period, Hispanics (OR 0.77) and Asians (OR 0.69) were significantly less likely to utilize telehealth services as compared to non‐Hispanic Whites. Also, Spanish (OR 0.78) and other non‐English‐speaking families (OR 0.62) were significantly less likely to utilize telehealth services as compared to English speaking families.

Discussion: Although overall office visits decreased considerably during the 2020 pandemic compared to the same period in 2019, the percentage of Hispanic patients decreased disproportionately during COVID months while the percentage of Non‐Hispanic Black and White patients increased. The largest percentage of growth was found in Non‐Hispanic Whites. Our findings reflect previous results on racial/ethnic disparities in health technology use, where Non‐Hispanic Blacks were reported to use medical record portals less frequently than Non‐Hispanic White patients (Walker et al. 2020), and racial/ethnic minorities were less likely to activate and use patient portals (Ancker 2011). Understanding and addressing access limitations, in addition to technology use differences between racial/ethnic groups, can help improve health outcomes for these populations. Mixed methods data collection should be deployed to better understand health technology use to design targeted interventions for reducing disparities.

Presenting Author e‐mail: Oluwaseun.oke@childrens.com

88. An investigation of the efficacy of the Telepractice service delivery model as compared to the Inperson service delivery model using a phonemic awareness intervention with Head Start Preschoolers

Pamela Storey ClinScD, CCC‐SLP¹, Selley Victor, EdD², Kathryn Cabbage, PhD³

¹Rocky Mountain University, Provo, Utah, USA; ²Rocky Mountain University of Health Professions, Provo, Utah, USA; and ³Brigham Young University, Provo, Utah, USA

Background: Telepractice was approved by the American Speech and Hearing Association (ASHA) since 2003, as defined as “the application of telecommunications technology to deliver speech language pathology and audiology professional services at a distance by linking client/patient or clinician to clinician for assessment, intervention, and/or consultation (ASHA, 2005a,b). Prior to COVID‐19, only 7% of SLPs in the US report using TP as part of their practice (Keck & Doarn, 2014). The low numbers of SLPs using TP may be due to the dearth of research in TP which would provide the evidence base needed to adhere to best practice. Although there are a number of investigations documenting the effectiveness of TP for children with a variety of speech or language‐based disorders, there are limited investigations conducted regarding phonemic awareness (PA) provided via TP for the underserved population of low socio‐economic (SES) Head Start preschoolers.

Methods: Design: Single‐Subject Adapted Alternating Treatment Design. Independent Variable: TP service delivery model versus In‐Person service delivery model. Dependent Variable: Percent correct of matching the same initial phoneme of a stimuli phoneme from an array of four pictures, after verbal antecedent. Subjects: 4 Head Start Preschoolers. An Initial Probe Phase (Baseline‐A1) was completed: phoneme pairs. Intervention Phase (B): The PA intervention was provided 4 times/week for 20 minutes, 12 sessions (short, intense intervention), randomly counterbalanced for time (am/pm), day and phoneme pairs using these variables to ensure the equivalence of behavioral sets: phonemic categories, developmental acquisition, number of trials, IV conditions, intervention protocol and PI interventionist. An e‐helper was present during TP sessions to supervise the preschoolers. Three Final Probe (A2) sessions were administered. Procedural fidelity was measured using interrater reliability by comparing scores between the PI and a second independent SLP observer reviewing session videos post‐intervention. A social validity scale was completed by the Head Start classroom teachers to assess the teachers’ perceptions of the TP and In‐Person intervention.

Results: Data analysis used in this investigation included: visual analysis to determine trend, level, slope and within/between conditions analysis; a 2SD band statistical analysis, the percent of non‐overlapping data (PND) analysis and a session to proficiency analysis. Effectiveness: Based on PND analysis, results indicate In‐P and TP service delivery models had an equally effective impact on the DV. Efficiency: Inter‐subject replications were examined. For the four participants, on average, the same amount of sessions was needed to meet proficiency in initial phoneme matching for both service delivery models. Fidelity of implementation was measured at 87% which was deemed sufficient and therefore did not impact the outcome measures (DV). Social Validity was measured using a 1‐5 Likert scale, indicated the teachers “strongly agreed” that students’ interest in phonemes, sounds in words, literacy and intervention activities had increased, as well as considered the TP intervention worthwhile.

Discussion: It is well‐documented that preschoolers living in low SES households present with deficits in early literacy (Lonigan, 1998) particularly, nearly 50% of Head Start (HS) preschoolers were measured to have early literacy deficits as reported by Carta et al. (2015). The findings from this investigation demonstrate the potential benefit for using the effective and efficient TP service delivery model when providing PA interventions by SLPs to HS preschool children at risk for low early literacy skills. ASHA has identified the use of TP as a solution to the nationwide shortages of SLPs, particularly for those living in rural, urban, and underserved communities (ASHA, 2010). The findings from this investigation contribute to the existing literature by demonstrating that for 4‐year old HS preschoolers, TP is an effective and efficient service delivery model in which to address early literacy skills, particularly for initial phoneme awareness known to have a positive impact on literacy skills.

Presenting Author e‐mail: storey.pamela.slp@gmail.com

89. Leveraging Telehealth to Care for Vulnerable Community‐Dwelling Patients during a Pandemic

Asantewaa Poku MPH, Karen Abrashkin, MD, Konstantinos Deligiannidis, MD, MPH, Joyce Racanelli, LCSW, Sabrina Randall

Northwell Health, House Calls Program, New Hyde Park, New York, USA

Background: Home‐based primary care (HBPC) brings comprehensive care to vulnerable patients with complex needs who struggle to access primary care due to their difficulty leaving home. These patients often experience higher rates of hospital utilization and require more urgent care given their age, multiple chronic conditions and increasing functional impairments. Our program delivers high‐intensity care using proactive patient management by our interdisciplinary care team and 24/7 access designed to provide a timely clinical response to patients in need. The COVID‐19 pandemic represented an especially high risk for these patients given their clinical complexity and potential difficulty accessing care due to guidelines meant to prevent spread of the disease. Regulations were adjusted to increase remote access to care using telehealth given these guidelines. We rapidly scaled our telehealth use to maintain continuity of care and provide medical support to keep our high‐risk patients safely at home.

Methods: Providing telehealth visits required a consent campaign that would quickly provide access to the largest number of patients possible. We leveraged administrative staff to consent our new and established patients one week in advance of their planned provider appointment and had our care managers consent patients as part of their scheduled telephonic visits. The consent process included gathering the required information to facilitate the visit and a test of the telehealth platform prior to the planned telehealth visit. Workflows and education about telehealth visit preparation and documentation were implemented prior to rolling out telehealth visits for the practice. This included training on use of the telehealth application, telehealth visit etiquette, and documentation and billing. Additional resources were made available to providers and care managers who had questions or required technical assistance.

Results: Out of the 1,710 unique patients on program, 1,212 patients were outreached for telehealth consent between March and May 2020. During this period, 864 patients consented to the use of telehealth, 247 either declined consent or had no way to access the service and 407 patients were either unable to be reached or pending outreach. Providers used telehealth to complete 791 new, return, acute and community paramedicine patient visits between March and May 2020. Of these, 58% of the billable telehealth visits were billed as level 4 or 5 visits and another 27% of visits were billed as level 3 visits. Care managers additionally completed 158 visits during this same time frame.

Discussion: The COVID‐19 pandemic created conditions that encouraged and expanded the role of telehealth as a way for vulnerable patients to access care. Telehealth helped to facilitate a high level of care and helped to maintain continuity of care for patients when access was limited. While telehealth is part of the solution for connecting patients to medical care, it is important to have additional ways to reach those patients who are unable to use it to get the support that they need.

Presenting Author e‐mail: apoku@northwell.edu

90. Integration of Telehealth into a Nurse Triage Workflow within a Connected Health System

Cynthia Zettler‐Greeley PhD¹, Joanne Murren‐Boezem, MPH, MD², Patricia Solo‐Josephson, MD¹

¹Nemours Children’s Health System, Jacksonville, Florida, USA and ²Nemours Children’s Health System, Orlando, Florida, USA

Background: Telehealth facilitates access to care, increases convenience, and reduces healthcare costs. Yet it is underutilized, while potentially unnecessary use of EDs is rising, particularly among pediatric populations. Over 1/3 of patients don’t use telehealth because they don’t know if it is offered by their provider. Thus, patient education may lead to reductions in unnecessary use of EDs and urgent care facilities over time, lowering costs while increasing convenience. On‐call nursing services offer one means by which patient‐families may be educated about health options, including telehealth, as appropriate for their child’s complaint. This 3‐year, mixed‐methods study explored a pediatric health system’s integration of on‐demand telehealth into on‐call, primary care, triage nurse workflow and examined patient telehealth use after nurse recommendation. Results may inform the extent to which unnecessary ED and urgent care visits are reduced through patient education and use of telehealth.

Methods: In 2017, Nemours Children’s Health System (NCHS) integrated its CareConnect (NCC) On‐Demand telehealth service into the workflow of KidsHealth On Call (KHOC), a Nemours‐sponsored nurse triage service providing support to Nemours’ primary care pediatricians, serving families seeking care for their child outside of business hours. KHOC nurses were trained by the NCC team on patient complaints appropriate for telemedicine referral and how to download the telemedicine application. During telephonic nurse triage, parents received treatment recommendations or referral. Parents referred to NCC received education about telehealth, including access and use, and nurses fielded questions. This study quantifies the extent to which parents who called the KHOC nurses seeking medical advice during the study period of October 2017‐ October 2019 took advantage of the telehealth recommendation for their child within 48 hours of their call. Retrospective EHR study data included demographics, chief complaints, nurse recommendations, and follow up visits for 115,000 patient‐families who contacted KHOC during the study period. Nine KHOC nurses were surveyed 3 years’ post‐integration on their perceptions of the feasibility of the NCC partnership.

Results: Initial analyses revealed that 706 of 115k patients utilized telehealth within 48 hours of triage nurse recommendation. Retrospective data analysis is underway to answer research questions: (1) Of the KHOC calls during the study period, how many patients were referred to telehealth/ER/UC/PCP and what was their chief complaint, (2) How many KHOC referrals to telehealth led to a completed visit, (3) Of the completed telehealth visits, what was the age, gender, chief complaint of the patients, and did it differ from patients referred elsewhere, (4) How many of the referred patients represented new users of telehealth, and (5) How many of the completed telehealth referral visits subsequently were referred to the ER and what was the chief complaint/diagnosis? Triage nurse survey comments reflected positive experiences with telehealth and offered suggestions for improving workflow. Nurses appreciated that telehealth was a referral option and noted that some parents requested it. Workflow sometimes was stifled by need for lengthy instruction regarding application download or insurance coverage questions. Additional qualitative analyses will summarize nurse perceptions of the successes and challenges of telehealth’s inclusion into the triage protocol.

Discussion: This 3‐year study was undertaken to examine how integrating an on‐demand telehealth platform into an after‐hours, nurse triage service may increase patient‐family awareness and use of telehealth while increasing access to quality care. The partnership occurred within a connected health system, whereby patients could be treated and cared for 24/7 while remaining within their medical home. The partnership represents a feasible method for introducing new patients to the benefits of telemedicine, highlighted by over 700 patients who completed a telehealth visit following nurse referral. Additional analyses will demonstrate the extent to which unnecessary ED and urgent care visits are reduced through the use of telehealth referral. Through nurse surveys, the KHOC/NCC relationship was noted to be positive for patient‐families. Further research is needed on how a connected health system may leverage telemedicine with nurse triage services to improve the patient‐family experience.

Presenting Author e‐mail: czettler@nemours.org

91. A No‐Show Rate and No‐Show Cost Comparison Between Epilepsy Patients Receiving Video‐Call Encounters and In‐Clinic Encounters

Manuel C. Alvarado MPH^1,2, Laurie M. Douglass, MD^1,2, Cristina Camayd‐Muñoz, MS¹, Rinat Jonas, MD^1,2, Madeline Niemann¹

¹Division of Pediatric Neurology, Boston Medical Center, Boston, Massachusetts, USA and ²Boston University School of Public Health, Boston, Massachusetts, USA

Background: Approximately 50 million people in the world have epilepsy, and up to 70% could live seizure free with proper access to care. In Massachusetts, the prevalence of epilepsy was 71,600 cases in 2015, where 12% of cases were represented by children 17 years of age and younger. In the field of pediatric neurology, the number of physicians is 20% below the national demand and there is a need for a reduction in no‐shows as they exhaust limited resources and can lead to negative health outcomes. In order to address this issue, video‐call encounters were implemented into the Division of Pediatric Neurology at Boston Medical Center (BMC) to improve access to care for patients with epilepsy. The financial impact of this implementation was examined by comparing no‐show rates, no‐ show costs, and revenue loss percentages between epilepsy patients who were scheduled for video‐ call encounters and epilepsy patients who were scheduled for in‐clinic encounters between June 1, 2017 and August 16, 2019.

Methods: Video‐call encounters were delivered through ACT.md (now Activate Care), a virtual care plan platform that allowed providers, parents, and patients to coordinate care and communicate through instant messaging and video‐calls. The patients included in this analysis were the 74 epilepsy patients who were scheduled for video‐call encounters (VC) through ACT.md and the 248 epilepsy patients who had ACT.md care plans but were scheduled for in‐clinic encounters (IC) between June 1, 2017 and August 16, 2019. EPIC electronic medical records (EMR) and a separate video‐call encounter log were used to gather data on appointment completions and no‐shows for these patients. Billing codes were provided by billing specialists in the BMC Department of Pediatrics and US dollar values were assigned to appointments based on their duration. A two‐sample t‐test was used to test whether the mean number of no‐shows for VC patients differed from the mean number of no‐shows for IC patients. This same test was used to examine differences in no‐show costs and revenue loss percentages between VC and IC patients.

Results: Between June 1, 2017 and August 16, 2019 there were a total of 1,076 scheduled appointments for this study population. 939 of these scheduled appointments were for in‐clinic encounters and 137 were for video‐call encounters. Overall, video‐call encounter patients had a 6% no‐show rate whereas in‐clinic patients demonstrated a no‐show rate of 15%. VC patients showed a revenue loss percentage of 6% where IC patients showed a revenue loss percentage of 14%. IC patients had a significantly higher revenue potential and contributed most to no‐show numbers, no‐show costs, and revenue loss percentages compared to VC patients. There was statistically significant evidence that the mean number of no‐shows for VC patients (0.1081) was 4 times less than that of IC patients (0.4564). There was also statistically significant evidence (p < .0001) that the mean no‐show cost for IC patients ($26.27) was 13 times lower than the mean no‐show cost for in‐clinic patients ($340.30).

Discussion: Based on these results, video‐call encounters appeared to effectively supplement in‐clinic encounters by yielding lower no‐show numbers, no‐show costs, and revenue loss percentages while also maintaining continuity of care for pediatric epilepsy patients. Overall, this implementation was associated with a two‐fold decrease in no‐show rates and revenue loss percentages in a specialty of medicine that is limited in resources and is experiencing a physician shortage. It must be noted that video‐call encounters cannot completely supplant in‐clinic encounters, however they are effective in facilitating more frequent patient‐physician encounters without requiring patients and their families to miss school and/or work. The long‐term effect of video‐call encounter implementation could lead to less travel costs and lost wages for pediatric patients and their families, which would be beneficial especially for patients that fall below the federal poverty line.

Presenting Author e‐mail: manuel.alvarado@bmc.org

92. An Innovative Partnership to Improve Dermatology Practice in the Primary Care Setting

Morgan Davis, MS, Sheree C. Melton, MD

University of Mississippi Medical Center, Jackson, Mississippi, USA

Background: Project ECHO was founded to address knowledge gaps for primary care providers. Originally started for hepatitis C treatment, this decentralized case‐based telementoring learning program has expanded to include topics like dermatology. Many primary care physicians receive insufficient dermatology training during medical school and residency. This is reflected in the vast discrepancy in correct diagnostic rate between dermatologists and primary care providers. Research also suggests that medical students and physicians are aware of telehealth but often prefer additional exposure and training opportunities. This need is also reflected in the American Academy of Family Physicians recommendation that family medicine residencies incorporate telehealth into their curriculum. The design of the UMMC Project ECHO for Dermatology takes into consideration the need for invested stakeholders and increased opportunities for dermatology training and telehealth exposure in medical education.

Methods: The hub team is a unique partnership of faculty from UMMC’s Departments of Dermatology and Family Medicine. The 2 family medicine faculty members provide invaluable insight and logistical support. Both have been essential in content creation for promotional material and the curriculum. The department of family medicine leveraged their relationships and assisted by providing contact information for community physicians who precept medical students. Our pre‐launch practice ECHOs benefited from having the family med residents as our live audience. Involvement of family medicine faculty has also facilitated the unique participation of medical students and family medicine residents. For their family medicine rotation, third year medical students are placed with community preceptors throughout MS. During orientation for this rotation, students are introduced to Project ECHO so they can assist interested preceptors with case submission. The goal is to have the medical students’ knowledge of Project ECHO lower the barriers that might prevent community providers from initially joining an echo session. Program evaluation measures include participant attendance, submitted cases, and a post participation self‐efficacy survey.

Results: Since September 2019, 52 unique participants attended at least one ECHO meeting (range 1 to 8). Most participants (75%) are family medicine resident physicians. Six medical students (12%) have also participated in addition to two community physicians who are part of the family medicine preceptor network. Five separate spokes sites have attended, including three Mississippi Family Medicine Residencies. In total, nine participants and two spoke sites presented 20 unique patient cases. Preliminary results (n = 17) of the self‐efficacy survey indicate that there is a wide variation in participant’s confidence in their ability to treat skin conditions. Operational feedback from participants included recommendations for wider outreach, in addition to making changes to the session times, curriculum topics, and the frequency of announcements. When asked about the quality of case presentations and discussions, 76% of participants ranked these aspects of ECHO as good or excellent.

Discussion: Most of the physicians that participate in UMMC’s Project ECHO for Derm are family medicine residents. The low participation from community physicians and medical students affiliated with the family medicine preceptor network can be partly attributed to the limitations created by COVID‐19. Considering the need for more dermatology and telehealth exposure, the UMMC family medicine residency has scheduled Project ECHO into their didactics and residents are encouraged to present cases. Literature indicates Project ECHO is yet to be widely incorporated into residencies, missing an opportunity to close multiple knowledge gaps. Project ECHO is a powerful tool for educating physicians and other healthcare providers but requires high stakeholder engagement for successful implementation. We overcame this barrier by creating a hub that included primary care stakeholders. This partnership also enabled us to expand ECHO’s reach beyond continuing education and into medical school and residency.

Presenting Author e‐mail: m.j.davis1991@gmail.com

93. Addressing Disparities in Child Behavioral Health: Findings from Randomized Controlled Trials Using Telebehavioral Health to the Home

Eve‐Lynn Nelson, PhD, FATA¹, Susana Patton, PhD, ABPP, CDE², Ann M Davis, PhD, MPH, ABPP¹, Karen Wambach, PhD, RN, IBCLC, FILCA, FAAN¹

¹University of Kansas Medical Center, Kansas City, Kansas, USA and ²Nemours Children’s Clinic. CITY, STATE, USA

Background: Telebehavioral health has great potential to bridge geographical distances, reduce burden for families, and make treatment, research, and education more available to the broader population. The need for evidence‐based interventions to the home has become even more pressing with the pandemic. The presentation will describe three clinical trials which each employ home‐based telehealth (secure real‐time videoconferencing) to deliver behavioral treatment to youth and parents. The presentation will feature research focused on children and adolescents with obesity, parents of young children with type 1 diabetes, and pregnant/parenting teens. Moreover, presenters will describe three different formats of video‐based treatment delivery (e.g, family, group‐based, and individual). The speaker will integrate cross cutting lessons from across the trials around tailoring interventions for diverse underserved families and considerations with recruitment, retention, analysis, and dissemination.

Methods: The presentation will share methods across the three pediatric psychology trials, emphasizing strategies for recruitment and retention in underserved communities and sharing intervention adaptations for telehealth. For the obesity trial, 19 rural elementary schools were recruited and randomized, resulting in 152 participating children and parents across the iAmHealthy group intervention and health coaching, or newsletter control group. Across Type 1 diabetes trials, 83 parents and their young children were enrolled in the group‐based telehealth intervention. Finally, the momHealth intervention recruited 63 adolescent mothers for the individual and group telehealth intervention that spanned the critical perinatal period; 8 weeks during the third trimester of pregnancy and 4 weeks postpartum. The multi‐behavior change intervention targeted healthy lifestyle; depression prevention; and breastfeeding.

Results: In the pediatric obesity trial, iAmHealthy participants compared with controls decreased the number of calories, increased the number of servings of fruits and vegetables, and decreased number of servings of “red” foods (i.e. junk foods). In the momHealth pregnant/parenting trial, baseline data for the first 50 participants will be presented‐26 adolescents in the Experimental group and 24 adolescents in the Control condition. Of those who had given birth (n = 41), 39 breastfed in the hospital. The speaker will discuss the ITT planned comparisons, including: 1) rates of initiation and duration of breastfeeding through a validated questionnaire; 2) healthy eating/active living patterns (as measured by diet recall and Physical Activity Monitors) from prenatal baseline to 3‐months postpartum; and 3) depression symptoms from prenatal baseline to three‐months postpartum. For the diabetes trials, parents reported significant pre‐post reductions in Hypoglycemia Fear, Parenting Stress, and T1D‐Specific Distress (all p < .05), and significant reductions in Hypoglycemia Fear, compared to waitlist (p < .04). Children with out‐of‐target HbA1c’s at baseline experienced a significant reduction in HbA1c (p < .05).

Discussion: Across the 3 telebehavioral health RCTs, using video‐based telehealth to deliver interventions to the home proved feasible and effective across relevant child health domains. Home‐based telehealth helped overcome challenges in reaching underserved rural and urban families for participation in clinical trials. Research strategies that were utilized to support safe continuation of the trials during the pandemic will be shared. Benefits of the multiple behavior change research framework will be shared in relation to future pediatric telehealth trials across intervention and prevention. Future directions around trials of interventions using multiple synchronous and asynchronous technologies tailored to the child/family will be described. The speaker will summarize upcoming dissemination of these telehealth interventions and associated research.

Presenting Author e‐mail: enelson2@kumc.edu

94. Transforming Substance Abuse Care While Maintaining Quality Care and Patient Satisfaction in Response to COVID

Steve North, MD, MPH, Channah VanRegenmorten, MSSW, PMP

Eleanor Health, City, State, USA

Background: The use of virtual care to treat substance use disorders has been limited due to regulatory constraint. A technology enabled start‐up focused on whole person substance care launched in September, 2019 in a non‐Medicaid expansion state. Focused on whole person care and strong community outreach, the practice grew to four bricks and mortar practices by March, 2020 using telemedicine to share medical providers between practices. On March 10, a “State at Home Order” was issued due to the COVID pandemic forcing a rapid conversion of the practice from clinic‐based care to predominantly virtual care. The suspension of the Ryan Haight Act combined with changes in state Medicaid policies allowed this practice to rapidly transform from predominantly in person care to primarily virtual care over the course of one month. At the onset of the COVID pandemic the organization set clear goals for continued growth in patient volume and maintaining clinical outcomes through this transformation.

Methods: Data for this quality improvement study was collected through EHR data, billing data and a HIPAA protected online patient satisfaction survey. Data presented in this abstracted was collected through May 31, 2020. Data will continue to be collected and analyzed through September 30th for this presentation. Additionally, a survey of all patients was conducted in June, 2020 looking at their preferences regarding care delivery following the COVID pandemic. This was analyzed by type care being provided (medical, behavioral health, nursing case management, peer support specialist, group visit) and distance from their home to the nearest clinic.

Results: During the week of March 8th 0% of patients were seen entirely virtually. Within 3 weeks of the “State at Home” order being issued (week of March 29th) 83.7% of patients were seen entirely virtually. During the same period no show/cancellation rates increased marginally from 18% to 24.2%. Through the transition to virtual care our substance use disorder practice continued a high level of patient satisfaction with: 97% of patients indicating they felt cared for; 79% of patients continuing in care (average 90 days retention for SUD practices rate is < 50%); and a 79 eNPS score. Clinical outcomes were pre/post conversion to virtual care demonstrated no variation in clinical outcomes: 64% members with improved PHQ‐9 score (depression), 56% members with improved GAD7 score (anxiety) and 68% members with improved Recovery Capital Score (35 social determinants). Eight weeks after the “State at Home” orders virtual patient acquisition rates had returned to pre‐COVID in‐person levels. The survey of patient preferences post‐COVID found that 70.2% of patients would prefer most or all of their care to be provided virtually. Distance from patient home to the nearest clinic had little impact on patient preference outcome.

Discussion: Our nation faces increased rates of patients with substance use disorders overdosing and relapsing due to limited access to treatment it is critical to use telemedicine to increase access to care. The analysis of data from an innovative practice demonstrates that a technology enabled substance use disorder treatment program was able to rapidly transform how it delivered care to continue to expand the number of patients it cared for during a time when traditional substance abuse practices were being forced to close their doors. Multiple technology and operational challenges were navigated to sustain a high level of clinical quality and continue growth. These included: performing remote drug screens; technology literacy; adapting an interdisciplinary, collaborative model; and, patient access to reliable technology. Lessons learned from this practice’s experience have broad applicability for substance use disorder treatment programs both during the current pandemic and beyond.

Presenting Author e‐mail: Steve.north@eleanorhealth.com

95. Public Insurance Status and Primary Care Telemedicine Visits for Children During the COVID‐19 Pandemic

Nymisha Chilukuri, MD, Julia M. Kim, MD, MPH, Helen K. Hughes, MD, MPH

Division of General Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Background: We have known for over a decade that telehealth has the potential to improve care access for underserved population of children, including those insured through state Medicaid programs. However, prior to the COVID‐19 pandemic, there were many logistical, regulatory, and financial barriers to telehealth implementation for publicly insured children. The pandemic has brought about an astoundingly face‐paced adoption of telehealth. In April and May of 2020, over 70% of ambulatory care at the Johns Hopkins Children’s Center was delivered by video visits – a 220‐fold increase in comparison to just two months prior. However, little is known about whether this rapid implementation has equitably impacted publicly insured children. The objective of this study was to evaluate the relationship between patient insurance status (public versus private) and telemedicine visits in pediatric primary care clinics at the Johns Hopkins Children’s Center during the COVID‐19 pandemic.

Methods: This was a descriptive, retrospective analysis of institutionally available data from an electronic health record dashboard. We extracted data for visits in 4 Johns Hopkins pediatric clinics from March 15th 2020 to June 15th 2020, which was the period of rapid telehealth expansion after the declaration of the Public Health Emergency. This included three pediatric primary care clinics and one adolescent medicine clinic located in Baltimore City. We included any completed ambulatory telemedicine visit in these four clinics (video or phone) for patients age 26 years or younger. We compared the percent of visits conducted with publicly insured patients via telemedicine in 2020 with a baseline percent of visits conducted with publicly insured patients for in person visits from these same clinical sites before the pandemic during calendar year 2019.

Results: No telemedicine visits were conducted in these four clinics prior to March 2020. From March 15, 2020 to June 15, 2020, a total of 1,356 telemedicine visits (1,289 video visits and 67 telephone) were completed. This represented 41% of all visits during this time period (1,356 via telemedicine, 1,960 in person, 3,316 total visits). This total visit volume (telemedicine plus in‐person) was 50% of the total clinical volume in the same 13‐week time period in March‐June of 2019. Out of the total telemedicine visits (video and phone), 85% were with patients with public insurance. This is in comparison to a pre‐ pandemic baseline of 83% of in‐person visits being conducted with patients with public insurance during 2019. The rate of telemedicine visit increased each week through this time period, reaching a peak of 174 visits in the week of May 18. The percent telemedicine visits conducted with publicly insured patients remained stable over the 13‐week implementation period.

Discussion: In response to the COVID‐19 pandemic, there was a rapid implementation of pediatric telemedicine in pediatric primary care practices at the Johns Hopkins Children’s Center. Overall, the proportion of telemedicine visits with patients who had public insurance was similar to pre‐pandemic baseline visits with this population. This was true even by the 2^nd or 3^rd week of the rapid implementation. These findings suggest that insurance status was not a factor in uptake of telemedicine for patients and providers during this initial period. Telemedicine may be a feasible and accessible modality of care in pediatric primary care clinics serving patients insured through Medicaid. Next steps include investigating other patient factors that may impact access to telemedicine including income, neighborhood factors, and broadband internet access.

Presenting Author e‐mail: nchiluk1@jhmi.edu

96. Evaluating Virtual Care Superusers during COVID‐19

Weyjuin Chao MD, Nicholas Genes, MD PhD

Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA

Background: Emergency department (ED) superusers has been an area of interest given their disproportionate resource utilization. Prior studies on ED superusers have generally accepted a definition of greater than 4 ED visits per year. This accounts for 21% to 28% of all ED visits while comprising only 4.5% to 8% of all ED patients. This definition has spurred the investigation of superusers in other medical subgroups, such as the EMS, psychiatric ED, and imaging superuser. Virtual care (also termed telemedicine or telehealth) has established practices including urgent care. The surge of COVID‐19 in New York City in the Spring of 2020 led to a dramatic expansion in the use of virtual care, given quarantine measures and public concern for infection during in‐person care. With increased utilization, superusers of our virtual urgent care service, Mount Sinai Now, were observed. We sought to characterize the frequent users of our telehealth platform to better understand their healthcare access needs.

Methods: We reviewed visit data from the Mount Sinai Now virtual care platform (Teladoc, Purchase, NY) from the period between March 1 and April 30, 2020 to identify users who had accessed our platform 5 or more times. Additional demographic information on these patients, as well as insurance information, past medical history, diagnoses and prescriptions, were available through our electronic medical record (Epic Systems, Verona, WI).

Results: 5,604 patients accounted for 7,639 separate telehealth visits. 75 (1.3%) patients called 5 or more times for a total of 496 (6.5%) visits. The highest number of visits from a patient was 18. Superusers tended to be female (57%) and young (average age 36.7). 70% of superusers have insurance. 44% of superusers were White, 29.3% Hispanic, and 16% African‐American. Telehealth superusers are healthy. 34.7% reported no medical problems, 37.3% with 1 problem, 22.7% with 2 problems, and 5.3% with 3+ medical problems. The most common medical problems were psychiatric, followed by asthma, then hypertension. Superuser chief complaints were overwhelmingly (70.5%) COVID‐19 related. 54.8% of these were upper respiratory (sore throat, rhinorrhea), lower respiratory (cough, chest pain, shortness of breath), and constitutional (fever, malaise) symptoms. 10.6% were for asymptomatic COVID‐related inquiries. 13.2% were due to anxiety or stress 28.1% of repeat visits were within 24 hours with a majority (60.5%) within 72 hours of a prior telehealth visit. 25.3% of patients ended up going to an ED and 16% to an urgent care. Almost all (73) were new virtual care users. 60% had no prior visit in our health system. 48% continued telehealth past April.

Discussion: Virtual care can provide patients with safe, convenient and individualized medical advice, while reducing the in‐person risk of virus transmission and PPE consumption. With the influx of new virtual care patients, superusers were observed. Like superusers of the ED and other medical services, virtual care superusers merit study to better understand and address their needs. The preponderance of psychiatric comorbidities suggests a specific need for mental health options to be included in virtual urgent care services like ours. Further research is also needed to elucidate any meaningful differences between the superuser cohort and the non‐superuser cohort. There are several limitations to our study. Patients who discovered telehealth at the end of our data period may have been captured as superusers if the study period was extended. Though our healthcare system spans several EDs and UCs, it is unknown whether these patients may have visited one outside of our health system.

Presenting Author e‐mail: weyjuin.chao@mountsinai.org

97. Evaluation of an Immersive Virtual Reality Intervention among Emergency Room Nurses.

Meredith Galvin MS¹, Ahmad Aalam, MD^2,3, Ali Pourmand, MD, MPH², Neal Sikka, MD²

¹School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA; ²Department of Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA; and ³Department of Emergency Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Background: Fatigue associated with intensive work schedules has numerous short and long‐term physiological and psychological consequences, which can negatively impact cognitive performance in numerous settings1. This is particularly applicable in shift workers’ health, where alertness is essential for doctors and nurses working 8+ hour shifts at a time. Previous studies have reported beneficial effects of napping on subsequent performance and self‐reported mood in doctors and nurses working ER shifts. However, napping can be time consuming, and memory measures directly after the nap actually worsened slightly.2 Therefore, other time‐effective interventions to combat fatigue and improve alertness are necessary. Virtual Reality (VR) has successfully shown to reduce stress, promote relaxation, and improve overall emotional well‐being. This study aims to examine the effectiveness of a 10‐minute Virtual Reality intervention on perception of stress during shifts on emergency room nurses.

Methods: Nurses were prospectively enrolled as volunteers from the George Washington University Emergency Department. Subjects completed a baseline Oldenburg Burnout Inventory and the NIH Perceived Stress Survey beforehand. Subjects were given the option to have a 10‐minute VR break or a “wild‐ type” (WT) break during which they did whatever they chose. We used a Samsung Gear Headset with games, travel, and relaxation content from AppliedVR (a VR platform designed by AppliedVR Inc. that offers immersive VR experience through a wide range of VR content). Nurses were surveyed on their subjective alertness, stress, anxiety, confidence, mood, busyness and fatigue at the beginning, before and after their break, and at the end of shifts (day, evening or swing). A Psychomotor Vigilance Test was given at each interval to objectively measure alertness. Various statistical analyses such as factorial design, time series, linear and logistic regression, categorical and t‐test were used to analyze the data.

Results: We collected 28 baseline and 128 observational events from November to December 2019. In total, we enrolled 26 participants, 1 participant dropped out, 88% (22/25) were female, and 4% (1/25) reported nonbinary. The mean age of participants was 32.9 (SD = 11.7). The average years of practice since graduation from highest training was 2.76 (SD = 0.93). Data was collected for shifts with a routine break (Wild‐type, WT) and virtual reality break (VR). A total of 103 observations were made 48 (46.6%) WT, 55 (53.4%) VR) over 4 observation points. Participants rated on a 1‐10 Likert Scale their shift from worst to best, their mood from terrible to great, and their busyness from very busy to not busy. We used an unpaired T‐test to compare responses. When participants had a WT break, they rated their shift a mean score 6.25 before their break and 5.5 after (p < 0.12), their mood a mean score 5.92 before their break and 6.0 after (p < 0.45), and their feeling of busyness at 5 before break and 4.2 after break (p < 0.22). In the VR group, mean shift rating before break was 5.1 and after 6.2 (p < 0.07), their mood rating before break 4.9 and after break 6.3 (p < 0.047), and their busyness before break 5.1 and after break 4.9 (p < 0.41).

Discussion: This is an initial analysis of pooled data examining the use of virtual reality to improve stressful healthcare related shift work in nurses. Preliminary analysis indicates that VR participants improved perception of mood was statistically significant. There may be additional insights to the benefit of an immersive VR intervention to participants when a person is compared to themselves. The results of future analysis may help to establish a new model for managing healthcare provider alertness, stress and anxiety and provide insights into viable and effective interventions to improve these parameters for other occupations, especially in shift workers performing complex and critical actions. Further analysis is indicated to better understand the effect of VR.

Presenting Author e‐mail: meredithgalvin@gwu.edu

98. Remote Patient Monitoring for COVID‐19 Patients After ED Discharge

Ahmad Aalam, MD^1,2, Erin Kane, MD², Adam Rutenberg, MD², Colton Hood, MD², Neal Sikka, MD²

¹Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia and ²Department of Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA

Background: One of the most feared complications of COVID‐19 is respiratory failure. Though some patients are known to be at higher risk of complications of COVID‐19, current understanding of the natural history of COVID‐19 is incomplete, and which patients will decompensate and at what time is currently unpredictable. Given the capacity constrained health care systems, patients at low risk of decompensation should be managed as outpatients. To allow for early detection of worsening clinical status, expand hospital capacity, and provide extended access to vulnerable patients, our Emergency Department (ED) created a remote patient monitoring telehealth program for Covid‐19 patients discharged from the ED. This RPM program uses patient supplied physiologic data to monitor patients through once daily e‐mail monitoring.

Methods: To facilitate rapid implementation of monitoring to COVID‐19 discharged patients we utilized already available resources including Power Automate, Forms (Microsoft Corporation, Redmond, WA) and QuickBase (Quickbase, Cambridge, MA), to build a secure, low cost, web‐based, monitoring application. A process map (Figure 1) was built accounting for daily data collection (symptoms and vital signs) via electronic survey (Figure 2) sent by email. Vital signs are obtained by a thermometer and pulse oximeter provided to each patient at the time of ED discharge, along with written and video instructions. A tiered escalation model was developed to account for non‐responding patients and patients with abnormal findings. Survey responses are automatically analyzed and flagged for human follow‐up if they indicate possible deterioration. An EMT calls flagged patients to confirm and verify the validity of the trigger. Based on predetermined criteria (Figure 1) one of three patient actions will be recommended; return to monitoring, escalate to a telemedicine appointment, or refer to the emergency department with 911 activation if necessary.

Results: 58 patients were monitored; 42 (72%) patients triggered an automated flag, 27 (47%) patients were escalated to a telehealth consult, 10 (17%) patients were referred to the emergency room and no patients needed 911 calls. Total time of human interaction by healthcare providers was 2122 minutes. Patients responded to our survey 1265 times, 525 (42%) were conducted over the phone for patients whom could not fill the electronic survey on time, and 174 (14%) needed a human touchpoint for automated trigger clarification. Average of days patient was monitored was 23 days, and average days of completed responses (survey and vital signs) was 15 days about 65% of days monitored. More data and analysis to follow pending IRB approval.

Discussion: This an initial analysis of pooled data examining the use of remote patient monitoring of COVID‐19 patients after being discharged from the ED that shows remote monitoring of vital signs and symptoms of patients diagnosed with COVID‐19 and discharged from the ED is feasible. Patients were able to participate and completed responses with an average of 15 monitored days. Almost half of our participant population needed a telehealth consult and only 17% needed a referral to the ED. This high utilization rate may be related to the unclear natural history of COVID‐19 disease. This is an ongoing longitudinal program that will hopefully provide further insights. More study is needed to understand efficacy, costs, risks, and impact of post‐acute care remote monitoring during the COVID pandemic. Further, remote monitoring has been traditionally focused on the management of chronic disease. More study is required to understand how these models adapt to support the monitoring of acute condition.

Presenting Author e‐mail: Dr.aalam@hotmail.com

99. Zero to 100 in 30 ‐ Rapid Deployment of Sustainable Virtual Care Programs During COVID‐19 Pandemic

Tamara Perry BA‐SLP, MA‐IOC^1,2

¹Children’s Health System Texas, Dallas, Texas, USA and ²Pediatric Special Interest Group ‐ American Telemedicine Association, Ballston, Virginia, USA

Background: March 2020, the Novel COVID‐19 virus began spreading quickly across the country and in Northern Texas, the location of Children’ Health System of Texas. Almost immediately, health care systems were put on alert to manage patient care and do so in a virtual manner when at all possible. Children’s Health implemented telemedicine in 2013 with hospital centralized virtual care and 2015 a direct to consumer service line. For pediatric patients as well as adults, providing urgent care and behavior health consults. This virtual modality was essential in the connected health model during transitions of care during the pandemic. First phase implementation was ambulatory specialty clinics. Fifty‐three virtual practices were built offering at home virtual visits to patients over their phone, tablet or laptop– reducing the number of patients/providers entering the ambulatory clinic setting. Phase 2 included Free COVID‐19 screenings to provide care and reassurance for patients and families.

Methods: The ambulatory specialty clinics were equipped with 53 virtual practices to offer at home virtual visits to patients over their phone, tablet or laptop– reducing the number of patients and providers having to come into the ambulatory clinic setting. Since March 19, ambulatory clinics have had over 20,000 virtual visits; increasing their utilization of virtual consults by 16,000%. The Children’s Health Virtual Visit direct to consumer application has seen a spiked increase in visits since the pandemic with a 500% increase in visits vs this time last year. Free COVID‐19 screenings were offered to patients at the beginning of the pandemic to provide care and reassurance as patients and families experienced symptoms related to the infection. Telemedicine inside the walls of the hospital expanded as well with near 22 new service lines with a goal of reduction of PPE and lessen exposure for patients and clinical teams. Bedside telemedicine has had over 1,300 virtual touchpoints achieved since deployment. As a result the virtual health team has received several awards across virtual care community related to their rapid deployment and expansion of virtual care during the current pandemic.

Results: Virtual group training for all providers and clinical staff was conducted along with documentation in LMS. The medical affairs team streamlined the credentialing process to expedited approvals by 24 hours. All providers completed asynchronous telemedicine training as well as virtual mocks and demonstration of competency to direct and present a telemedicine consult. 1,350 providers and 1,192 nurses and clinical staff completed this process. Physician, nursing and operational leadership met daily to collaborate on implementation goals, barriers and decision making towards transitioning to 100% virtual care in the ambulatory setting. Since the March 19 implementation kick‐off, Since March 19, ambulatory clinics have had over 20,000 virtual visits; increasing their utilization of virtual consults by 16,000%. All clinical practices are equipped to deliver consults virtually now. The management of teach virtual practice is currently being transitioned to the program administrators so daily operation details can be adjusted as needed to meet individual practice needs. An ambulatory super‐user group will liaison between with the VH team to learn and educate their areas on platform enhancements as well as operational changes.

Discussion: Our VH team and clinical teams at Children’s Health Texas experienced many successes and lessons learned during the deployment of telemedicine during this pandemic. Early 2019, a telehealth billing advisory committee was developed. This team includes compliance, privacy, billing/coding staff and legal. The goal of the committee is to review existing and requested telemedicine programs to determine billing status and regulatory/laws that effect reimbursement. Having stakeholders at the table strengthen the rapid deployment of telemedicine – swift decision making and collaboration across leadership was a success. There were certain inequities identified. Care gaps for patients without access to Wi‐Fi, translation was a huge missing component of most technology platforms and rapid transition from in‐office visits to at home visit was a learning challenge for some clinical support staff. This presentation will speak to how these issues were identified and conquered.

Presenting Author e‐mail: tamara.perry@childrens.com

100. Patient Satisfaction of Telemedicine Remote Patient Monitoring (RPM) Services: A Systematic Review

Parker Rhoden MHA, Jillian Harvey, MPH, PhD, Heather Bonilha, PhD, CCC‐SLP

Department of Healthcare Leadership & Management, College of Health Professions and Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA

Background: There is no gold standard telehealth patient satisfaction instrument. The validity and reliability of RPM patient satisfaction instruments were examined through a systematic review.

Methods: 777 articles were used in the systematic review. The quality of survey instrumentation methods was assessed based on validity and reliability using the Terwee et al. framework. 36 studies were included in the analysis.

Results: For content validity, 9 out of 11 studies received a “good” quality rating; approximately half of the studies received a “good” quality rating for construct validity. For reliability, all studies received a “poor” or “fair” quality rating.

Discussion: RPM Survey instruments are used to assess patient satisfaction. Using the Patient Experience Questionnaire and Client Satisfaction Survey is recommended for assessing RPM patient satisfaction.

Presenting Author e‐mail: rhoden@musc.edu

102. Telehealth Competencies to Train the Current and Future Physician Workforce

Sarah Hampton BA, Scott Shipman, MD, MPH

Association of American Medical Colleges, Washington, DC, USA

Background: Before the COVID‐19 pandemic struck, the healthcare system was being transformed by the growing adoption of a wide range of health technology services. Yet there was a lack of consensus and no standard approach to educating and training providers on the use of these services—an agreed upon set of competencies ‐ observable abilities of physicians related to telehealth that integrate knowledge, skills, values and attitudes ‐ was needed in order for providers to deliver high‐quality care. In 2018, the AAMC partnered with telehealth leaders and advocates from across the country to develop a set of competencies to better support educators, providers, and patients. With the current COVID‐19 pandemic and the rapid uptake of telehealth by both patients and providers, these guidelines are needed now more than ever. Based on the work of this expert advisory panel of telehealth leaders and advocates, the AAMC is set to release the telehealth cross continuum competencies in the summer of 2020.

Methods: The AAMC assembled a panel of experts in telehealth to identify the skills required to deliver high‐quality care through telehealth, ultimately leading to the development of competencies. Once identified, the skills were transitioned to cross continuum competencies, tiered at three levels (student, resident and faculty). Development process summary: (1) Define the scope of the competencies or the construct. What does a student/resident/faculty do, know and value in relation to telehealth?, (2) Engage diverse stakeholders and collect data to understand the nature of the construct, (3) Draft the competencies, (4) Have reactor panels of subject matter experts, patients, frontline clinicians, and educators review iterative drafts of the competencies using a modified Delphi process, and (5) Review and update competencies periodically. To collect feedback, two electronic questionnaires were sent to over 300 reactors after the first and second drafts of the competencies. The feedback was used to inform the subsequent revision of the competencies. In reaching the final set of competencies, the panel reviewed and refined the competencies to ensure they were focused on the needs of patients, based on consensus, & grounded in a common framework.

Results: Over the course of 18 months, the committee identified the skills needed for clinicians to provide high‐quality care via telehealth and then transitioned the skills into telehealth competencies. The competencies are tiered based on the level of learner: entering residency (recent medical school graduate), entering practice (recent residency graduate), and experienced faculty physician (3‐5 years post‐residency), and are intended to be applicable to all physicians regardless of specialty. These telehealth competencies are intended to supplement existing competencies while providing more telehealth‐specific guidance to better support educators design and deliver curricula on telehealth and integrate telehealth into training and professional development. They are not intended to be used for accreditation for schools, programs, or institutions. This presentation will share the final set of domains and related competencies.

Discussion: With the COVID‐19 pandemic, health systems have implemented or scaled telehealth programs without formally educating or training providers and patients. With telehealth as a primary tool for delivering care, it is crucial that providers be educated and trained on its use to ensure high‐quality care. This set of telehealth‐specific competencies is meant for providers at all levels. The AAMC looks forward to working with institutions and learning how best to incorporate the competencies into curricula and training. We welcome feedback on the competencies at any time.

Presenting Author e‐mail: sahampton@aamc.org

105. Virtual Urgent Care: from Hurricanes to Pandemics

Parnaz Rafatjou, MHA, MBA, Dee Ford, MD, MSCR, Meghan Glanville, MHA,

Jillian Harvey, MPH, PhD, Kathryn King, MD, MHS, Ryan Kruis, MSW, Ed O’Bryan, MD

Organization, City, State, USA

Background: During disasters and pandemics, patients may experience travel restrictions, and an inability to access timely care. A promising approach to access care during these periods is the use of Direct to Consumer (DTC) telehealth. According to a recent Center for Disease Control and Prevention (CDC) report, the most common causes of death during hurricanes are linked to exacerbation of existing medical conditions, power outage, and chronic illnesses. The National Oceanic and Atmospheric Administration predicts up to 25 named storms in 2020. The World Health Organization declared COVID‐19 a global pandemic on March 11, 2020 During times of COVID‐19 social distancing, facilitative care. To meet the needs of patients and ensure the safety of providers, health systems were forced to rapidly adjust standard care processes and deploy new delivery approaches to screen and care for COVID patients, as well as continue to meet the routine care needs of populations.

Methods: We implemented a no‐charge DTC virtual urgent care service during Hurricanes Florence and Dorian and leveraged that work for COVID‐19 screening. Utilizing program and electronic health record data, we present a descriptive summary of utilization, user demographics, and outcomes during a two types of disaster response.

Results: During Hurricane Florence, a no‐charge code was disseminated to facilitate access to virtual urgent care visits for South Carolinians, whose access was limited due to closures, hazardous traveling conditions, or evacuation. From 09/11/18‐09/16/18, 166 patients utilized this service, 66% of patients were female. The same procure was used between 9/2/19‐9/15/19, for Hurricane Dorian, and 678 virtual urgent care visits were completed (77% female). Telehealth utilization increased substantially for COVID‐19, with 27,504 patients screened using the no‐charge referral code between March‐June, 2020 (72% female) 43% of those screened were referred for COVID‐19 testing. Across both hurricanes and the pandemic DTC visits, the most common complaints were sinus infection, cough/cold/flu, and urinary tract infection. The majority of patients across all three events were in the age range of 25‐34 (30%).

Discussion: Virtual urgent care traditionally, provides fast access to care for low‐risk conditions. Consistent with the literature, for many types of telehealth utilization, women ages 24‐34 were the most frequent consumers of virtual urgent care services during times of natural disaster and pandemic in 2018‐2020. The existing telehealth infrastructure that was developed and tested during two hurricanes, was rapidly expanded to meet the screening and triage needs during COVID‐19. Including linkages to the EHR and training, privileging, and credentialing over 100 Advance Practice Providers to meet demand. Offering a no‐charge code for virtual urgent care visits contributed to meeting state‐wide access to care needs during states of emergency. The creation of a robust telehealth infrastructure can make the safe continuity of care possible. The DTC service may be under increased demand, if 2020 includes a situation where populations are required to evacuate for a hurricane during the pandemic.

Presenting Author e‐mail: harveyj@musc.edu