Hello, my name's Helen Hughes, and I am the Assistant Medical Director for the Johns Hopkins Office of Telemedicine, I'm also the Medical Director for Pediatric Telemedicine at the Johns Hopkins Children's Center. I'm going to be speaking with you in this module about research and evaluation of telemedicine There's been a lot of buzz in the media right now discussing whether or not, the rapid changes we've experienced at telemedicine will be long-lasting. Ultimately, the future of telemedicine depends on three main things: the patients and providers, the experience that they've had with telemedicine and do they want to keep doing it, are the regulatory changes that have been put in place kept the road back, and what evidence have been developed to determine whether these changes should be sustained. Whether telemedicine continues to be a part of our practice, relies heavily on whether the regulatory and reimbursement changes that have been in place recently, remain the same. Payers and regulators will have to decide based on a calculation of risks and benefits. On the benefit side, you have improved access and reduced cost, patient experience, and potentially improved outcomes. However, on the downsides, you also have potentially misdiagnosis, litigation, and increased use and cost. It's going to be really important that the medical community provides evidence around telemedicine to help sustain reimbursement. Next, I'll be writing a brief review of some evidence around telemedicine as well as strategies for research and evaluation. We'll be reviewing an evaluative framework for telemedicine research and evaluation, exploring some examples of telemedicine research, and also discussing some national resources and networks. This is an example of an appendix in this measures framework, that shows some initial measure concepts. For example, in the domain of experience and the sub-domain of patient family and caregiver experience, you can see some measure concepts which include, for instance, that the patient demonstrated an increased confidence in their care plan, and that the patient demonstrated an increased understanding of their care plan. The report includes these types of measure concepts for all domains and sub-domains. Then this slide includes the appendix from this framework that has a very specific initial measures. You can use this as a reference, but for example, this has some very specific measures under measure descriptions for COPD, that have been developed in the literature. Next, I'll transition to speaking about a few examples of telemedicine research. Recently, the Cochrane Library published this COVID-19 remote care through telehealth compendium, which included a number of Cochrane reviews on the subject of telemedicine and research. One of these Cochrane reviews from 2015, was titled, "Interactive telemedicine effects on professional practice and health care outcomes." They reviewed over 93 randomized trial and summarized the following findings. For heart failure, there was similar outcomes when using telemedicine in comparison to in-person care, but they also showed improved quality of life with telemedicine. For diabetes, there have been some studies to show improved blood glucose control, in patients in whom telemedicine has been used. For mental health and substance abuse, in many studies show no difference in therapeutic effect with use of telemedicine and some improved care access. A few studies have reported improved blood pressure control and respiratory condition control when telemedicine is used. However, the authors note that a major barrier to conducting research in this area is the rapidly evolving technology of telemedicine is often out of step with the time it takes to conduct a research. Another Cochrane review in 2016 discussed remote versus face-to-face checkups for asthma, and found that current randomized evidence did not demonstrate any important differences between face-to-face care and remote care for asthma checkups, but ultimately found there's insufficient information to rule out differences, and thus was not particularly clear on whether or not telemedicine should be used for this care. There's been a number of publications in the realm of school-based telemedicine for the pediatric population. This is a study from 2005, and the University of Rochester has really been a leader in this area. In that time they had five urban childcare centers participating in a telemedicine program for acute illness, and they found that there was a 63 percent reduction and absences from childcare due to illness when participants could receive remote acute care during their daycare session, as opposed to needing to leave daycare to have a checkup for an acute illness. Other researchers at Rochester, in 2018 published a large randomized trial related to asthma control using school-based telemedicine. They randomized 400 children attending 49 schools in the city of Rochester in the 2012-2016 period. They found in those children who were randomized to receive school-based telemedicine for chronic asthma care that they had more symptom-free days at six months as well as fewer ED visits and hospitalizations in the telemedicine group. Finally, in 2019, a group in South Carolina did a natural experiment study. In 2014 the South Carolina Medicaid program initiated a statewide school-based health program in which counties could voluntarily participate through the Medical University of South Carolina. Williamsburg County's shown here in red, participated in the program and was compared to the surrounding four counties that did not participate. They saw that telemedicine use in Williamsburg County was associated with fewer ED visits for patients with asthma, however, they did not see difference in ED visits for patients with other conditions. Finally, I'll conclude with overviewing some national research organizations and networks related to telemedicine research. There are some telemedicine dedicated organizations such as the American Telemedicine Association, but also many other national organizations are now engaged in telemedicine and can provide resources to clinicians and researchers including the Association of American Medical Colleges, individual professional societies such as the American Academy of Pediatrics, the ACP, and ECOG. A number of equity focused research groups are interested in using telemedicine to improve access to care, and so some Robert Wood Johnson Foundation initiatives are focused on telemedicine. There's also the Society for Education and Advancement of Research in Connected Health or SEARCH. Then historically HSRA has funded the National Consortium of Telehealth Resource Centers which has aimed to expand telehealth access in order to improve care for vulnerable populations. This is the American Telemedicine Association website, and you can see that they have a research section to connect researchers from across the country. This is the American Academy of Medical Colleges , AAMC website, and you can see a number of projects they have ongoing including Project CORE which is related to e-consults, as well as telehealth and academic medical center groups. The American Academy of Pediatrics has had a group called SPROUT, which stands for supporting pediatric research on outcomes and utilization of telehealth, which has been active for a number of years before the pandemic. This is a map from the website of the National Consortium of Telehealth Resource Centers, and this has been funded by the US Department of Health and Human Services and HRSA, and has really been administered to make sure that there are national and regional resources, to provide timely and accurate information on telehealth. The National Consortium is broken into multiple areas, and Johns Hopkins is located in the Mid-Atlantic Telehealth Resource Center. This shows the website, they can help with a number of things that institutions may need to help them build their telehealth programs, and then they also have some resources to help with business planning including an assessment and evaluation. Finally, if you're doing research in telemedicine and looking to publish it, a lot of national journals including JAMA and the New England Journal of Medicine have been interested in telemedicine-related research. There are also specialty-specific journals such as Academic Medicine, or Academic Pediatrics, or the Journal of Pediatrics, they may be interested in evidence around to telemedicine. There are business-oriented publications and news media groups such as the Harvard Business Review that may be interested, and finally, there are telemedicine specific journals such as the journal Telemedicine and e-Health. Thank you so much for listening to this module, and I wish you the best of luck in all of your research and evaluation of telemedicine.
