Salim M. Saiyed

Background: Telemedicine can improve access between physicians and patients and improve outcomes when deployed strategically in patients with chronic diseases. Telemedicine not only showed success in the care of chronic diseases, but its application also expanded exponentially during the COVID-19 pandemic. At our institution, a 12-week telemedicine diabetes “boot camp” was launched for patients with uncontrolled diabetes as an innovative means of providing accessible and high-quality patient care in primary care settings. Methods: Patients at primary care and endocrinology clinics with diabetes mellitus (DM) and glycohemoglobin (A1C) > 8.0% were voluntarily enrolled from September 2020 to November 2021. Dietitians and diabetes care and education specialists conducted biweekly visits via telemedicine for twelve weeks. Patient demographics, A1C, body mass index (BMI), and blood pressure were measured before and after the intervention. Results: A total of 134 patients were included, and 94 patients (70.2%) completed 6 visits for the full 12-week program. The mean A1C reduction was –2.09% ± 2.4%, and the A1C change was uniform across age groups, gender, ethnicity, BMI, and referral clinic type. A greater A1C reduction in patients who completed all 6 visits was noted although not statistically significant. We found a negative correlation between the initial A1C and the change of A1C. No significant BMI or mean arterial pressure change was observed. Conclusion: This single arm study demonstrated an improvement in A1C for all patients with a history of poorly controlled diabetes, regardless of patient characteristics. Higher initial A1C was associated with a greater A1C reduction.

Background: Little is known about the implication of launching virtual-first primary care (VPC) in a health system. Our experience and survey can guide others to establish their virtual-first programs. This study examines implementation, patient perspectives, and satisfaction with VPC at University of Pittsburgh Medical Center (UPMC). Methods: We conducted a Web-based survey to examine factors associated with the likelihood of early adoption and continued use of VPC. We used bivariate comparisons and cluster analysis to evaluate the results. The survey was sent to 1,420 patients seen between August 2022 and January 2023. Responses related to demographics, doctor-patient relations, savings, experience, and future preferences of use were aggregated. To evaluate the relationship between demographics and survey responses, we conducted univariate analysis. Results: Females and patients between 40 and 50 years of age were the primary users and indicated the most interest in continued use. Health insurance status seems not to be a significant predictor in the selection and use of VPC. Most (78%) felt that the physician-patient relationship was unimpaired. The survey showed that 90% of patients saved time by using VPC, and 66% reported saving money on tolls, childcare, or gasoline. Only 13% reported not wanting to continue VPC. Discussion: A majority of surveyed patients felt the doctor-patient relationship was not negatively affected in VPC. VPC programs can be implemented with high patient satisfaction in an integrated health system. VPC is acceptable to most patients, and further expansion of the model is warranted.

Background: The implementation of telemedicine and digital health technologies in healthcare has increased, but patients still need help adopting and utilizing these technologies. To address this, a Digital Health Navigator (DHN) program was implemented to evaluate the benefits of improving patients’ adoption. Objectives: To alleviate digital equity within hospitals, we introduced a holistic digital health navigator program designed to promote the utilization of digital tools among hospitalized patients. To implement a DHN program to improve patient adoption of digital portals to engage in healthcare. To learn from the program to further develop patient-facing portal education for hospitalized patients to expand to other hospitals. Methods: Over a period of thirty days, the DHN program conducted patient visits in two hospitals, on portal usage, collecting data, and adapting protocols based on patient feedback. Results: Feedback from patients indicated 98% of patients found the education and the DHN to be helpful. 92% recommend the UPMC Central PA Portal for accessing their healthcare information. The DHN program proves beneficial in promoting portal usage and addressing technological barriers experienced by patients. We provide strategies and recommendations on how to implement such a program. Discussion: We successfully implemented a digital health navigator program for hospitalized patients across two hospitals. Patients reported a positive perception and satisfaction with digital health navigator visits . Notably, our model overcomes challenges related to limited internet access and mitigates technology-related anxiety during hospital stays. The DHN program proved beneficial in promoting hospital portal usage and addressing technological barriers experienced by patients. Implementation and sustained adoption of digital technologies across a large healthcare organization can be achieved through a well-coordinated, team-based, and systematic approach with a DHN. We provide strategies and recommendations on how to implement such a program

Background: COVID-19 disrupted health care, causing a decline in the health of patients with chronic diseases and a need to reimagine diabetes care. With the advances in telehealth programs, there is a need to effectively implement programs that meet the needs of patients quickly. Objective: The aim of this paper was to create a virtual boot camp program for patients with diabetes, in 3 months, from project conception to the enrollment of our first patients. Our goal is to provide practical strategies for rapidly launching an effective virtual program to improve diabetes care. Methods: A multidisciplinary team of physicians, dieticians, and educators, with support from the telehealth team, created a virtual program for patients with diabetes. The program combined online diabetes data tracking with weekly telehealth visits over a 12-week period. Results: Over 100 patients have been enrolled in the virtual diabetes boot camp. Preliminary data show an improvement of diabetes in 75% (n=75) of the patients who completed the program. Four principles were identified and developed to reflect the quick design and launch. Conclusions: The rapid launch of a virtual diabetes program is feasible. A coordinated, team-based, systematic approach will facilitate implementation and sustained adoption across a large multispecialty ambulatory health care organization.

Background: Physician satisfaction with telehealth during the coronavirus disease 2019 pandemic is a strong indicator for future use. Validated surveys can guide improvement and future expansion of telehealth programs. Introduction: This study examines physician and advanced practice provider perspectives and satisfaction using telehealth at UPMC Pinnacle and to assess key predictors of future use in ambulatory care. Methods: A web-based Likert scale survey of UPMC Pinnacle physicians and advanced practice providers was conducted in May–June 2020. Cronbach's alpha was used to measure the survey's internal consistency. Crosstab analysis and multivariate regression were used to analyze the interrelationships between variables. Results: A significant majority (64%) of physicians responded positively that they enjoyed telehealth video visits. A majority (65%) felt that the physician–patient relationship was unimpaired during telehealth visits, but only 29% of the respondents felt they were able to examine the patients properly. Providers who experienced good video and audio quality were 3.68 times more likely to enjoy telehealth visits ( p < 0.001, 95% confidence interval 2.05–6.61) than those with less-than-optimal video and audio quality. Logistic regression shows a strong correlation between the audio and image quality and respondents' satisfaction with telehealth. Discussion: The key barriers for patients when using telehealth are perceived to be the ability to use a smartphone app, password management, or video/microphone features. For clinicians, barriers include problems with seeing and hearing on the platform. Conclusions: Patient education and improvement of audio and image quality are essential for improving telehealth usage and satisfaction.

BACKGROUND COVID-19 disrupted health care, causing a decline in the health of patients with chronic diseases and a need to reimagine diabetes care. With the advances in telehealth programs, there is a need to effectively implement programs that meet the needs of patients quickly. OBJECTIVE The aim of this paper was to create a virtual boot camp program for patients with diabetes, in 3 months, from project conception to the enrollment of our first patients. Our goal is to provide practical strategies for rapidly launching an effective virtual program to improve diabetes care. METHODS A multidisciplinary team of physicians, dieticians, and educators, with support from the telehealth team, created a virtual program for patients with diabetes. The program combined online diabetes data tracking with weekly telehealth visits over a 12-week period. RESULTS Over 100 patients have been enrolled in the virtual diabetes boot camp. Preliminary data show an improvement of diabetes in 75% (n=75) of the patients who completed the program. Four principles were identified and developed to reflect the quick design and launch. CONCLUSIONS The rapid launch of a virtual diabetes program is feasible. A coordinated, team-based, systematic approach will facilitate implementation and sustained adoption across a large multispecialty ambulatory health care organization.

Background Drug alerts are clinical decision support tools intended to prevent medication misadministration. In teaching hospitals, residents encounter the majority of the drug alerts while learning under variable workloads and responsibilities that may have an impact on drug-alert response rates. Objectives This study was aimed to explore drug-alert experience and salience among postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2), and postgraduate year 3 (PGY-3) internal medicine resident physicians at two different institutions. Methods Drug-alert information was queried from the electronic health record (EHR) for 47 internal medicine residents at the University of Pennsylvania Medical Center (UPMC) Pinnacle in Pennsylvania, and 79 internal medicine residents at the MetroHealth System (MHS) in Ohio from December 2018 through February 2019. Salience was defined as the percentage of drug alerts resulting in removal or modification of the triggering order. Comparisons were made across institutions, residency training year, and alert burden. Results A total of 126 residents were exposed to 52,624 alerts over a 3-month period. UPMC Pinnacle had 15,574 alerts with 47 residents and MHS had 37,050 alerts with 79 residents. At MHS, salience was 8.6% which was lower than UPMC Pinnacle with 15%. The relatively lower salience (42% lower) at MHS corresponded to a greater number of alerts-per-resident (41% higher) compared with UPMC Pinnacle. Overall, salience was 11.6% for PGY-1, 10.5% for PGY-2, and 8.9% for PGY-3 residents. Conclusion Our results are suggestive of long-term drug-alert desensitization during progressive residency training. A higher number of alerts-per-resident correlating with a lower salience suggests alert fatigue; however, other factors should also be considered including differences in workload and culture. No human subjects were involved in this project. The Institutional Review Board (IRB) was consulted, per guidelines at each institution, an IRB protocol approval was obtained as required by each institution. Program director approval was obtained from each residency program. Received: 17 August 2020 Accepted: 22 March 2021 Publication Date: 28 April 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background Concerns about the number of automated medication alerts issued within the electronic health record (EHR), and the subsequent potential for alarm fatigue, led us to examine strategies and methods to optimize the configuration of our drug alerts. Objectives This article reports on comprehensive drug alerting rates and develops strategies across two different health care systems to reduce the number of drug alerts. Methods Standardized reports compared drug alert rates between the two systems, among 13 categories of drug alerts. Both health care systems made modifications to the out-of-box alerts available from their EHR and drug information vendors, focusing on system-wide approaches, when relevant, while performing more drug-specific changes when necessary. Results Drug alerting rates even after initial optimization were 38 alerts and 51 alerts per 100 drug orders, respectively. Eight principles were identified and developed to reflect the themes in the implementation and optimization of drug alerting. Conclusion A team-based, systematic approach to optimizing drug-alerting strategies can reduce the number of drug alerts, but alert rates still remain high. In addition to strategic principles, additional tactical guidelines and recommendations need to be developed to enhance out-of-the-box clinical decision support for drug alerts.

Recent trends and research suggest health conditions of the Syrian refugees in Lebanon are deteriorating. The following case study highlights some of the problems that refugees encounter seeking health care services in Lebanon. A coordinated response from Non-governmental organization (NGO) with intense focus on non-communicable disease (NCD) is needed to avert further worsening of health conditions on the ground.

All default electronic health record and drug reference database vendor drug-dose alerting recommendations (single dose, daily dose, dose frequency, and dose duration) were silently turned on in inpatient, outpatient, and emergency department areas for pediatric-only and nonpediatric-only populations. Drug-dose alerts were evaluated during a 3-month period. Drug-dose alerts fired on 12% of orders (104 098/834 911). System-level and drug-specific strategies to decrease drug-dose alerts were analyzed. System-level strategies included: (1) turning off all minimum drug-dosing alerts, (2) turning off all incomplete information drug-dosing alerts, (3) increasing the maximum single-dose drug-dose alert threshold to 125%, (4) increasing the daily dose maximum drug-dose alert threshold to 125%, and (5) increasing the dose frequency drug-dose alert threshold to more than 2 doses per day above initial threshold. Drug-specific strategies included changing drug-specific maximum single and maximum daily drug-dose alerting parameters for the top 22 drug categories by alert frequency. System-level approaches decreased alerting to 5% (46 988/834 911) and drug-specific approaches decreased alerts to 3% (25 455/834 911). Drug-dose alerts varied between care settings and patient populations.