Publications

Purpose: To identify clinical and informational services that telemental health (TMH) providers need to be more successful in their practice. Methods: In February-March 2021, 472 TMH providers completed a cross-sectional survey. Providers indicated the degree to which they need clinical (e.g., build therapeutic alliances) and informational (e.g., learn about regulatory changes) services. Independent samples t-tests were conducted to examine differences in needs according to when telemedicine was adopted. Results: TMH providers neutrally-to-somewhat agreed they could benefit from clinical (M = 3.24; standard deviation [SD] = 0.78) and informational (M = 3.66; SD = 0.82) services. Prepandemic TMH providers reported a greater need for services that help them cultivate relationships with patients, monitor health conditions, and to remain updated about reimbursement processes. Conclusion: All TMH providers could benefit from information about the latest trends and best practices in telemedicine. Prepandemic providers could benefit most from policy-related updates and patient-engagement services.

BACKGROUND: Mental health care pivoted to telemedicine during the COVID-19 pandemic, and there is uncertainty around the sustainability of this rapid shift.

OBJECTIVE: This study examined how intentions to continue using telemedicine after the COVID-19 pandemic are influenced by provider perceptions of usefulness, ease of use, and professional social influence, facilitating organizational conditions.

METHODS: We conducted a web-based, cross-sectional survey of 369 telemental health providers between February and March 2021. A hierarchical linear regression analysis was conducted to predict intentions to continue using telemedicine after the COVID-19 pandemic.

RESULTS: Most providers began using telemedicine in March 2020 or later (257/369, 69.6%) and attended to ≥50% of their clients via telemedicine (299/369, 81.0%). Intention to continue using telemedicine after the COVID-19 pandemic was predicted by the telemedicine caseload (β=.10; P=.005), perceived usefulness in general (β=.10; P=.008), ease of use (β=.08; P=.04), social influence (β=.68; P<.001), and facilitating conditions (β=.08; P=.047).

CONCLUSIONS: Exploration of the predictors of telemedicine usage beyond the COVID-19 pandemic aids in surveillance of telemedicine usage, integration with future clinic workflows, and the shaping of public policy. It is important to consider telemedicine services as not only a response to a crisis but also an effective and useful solution for everyday life. Our results suggest widespread, sustainable telemedicine adoption.

OBJECTIVE: Virtual conversational agents, or chatbots, have emerged as a novel approach to health data collection. However, research on patient perceptions of chatbots in comparison to traditional online forms is sparse. This study aimed to compare and assess the experience of completing a health assessment using a chatbot vs. an online form.

METHODS: A counterbalanced, within-subject experimental design was used with participants recruited via Amazon Mechanical Turk (mTurk). Participants completed a standardized health assessment using a chatbot (i.e., Dokbot) and an online form (i.e., REDCap), each followed by usability and experience questionnaires. To address poor data quality and preserve integrity of mTurk responses, we employed a thorough data cleaning process informed by previous literature. Quantitative (descriptive and inferential statistics) and qualitative (thematic analysis and complex coding query) approaches were used for analysis.

RESULTS: A total of 391 participants were recruited, 185 of whom were excluded, resulting in a final sample size of 206 individuals. Most participants (69.9%) preferred the chatbot over the online form. Average Net Promoter Score was higher for the chatbot (NPS = 24) than the online form (NPS = 13) at a statistically significant level. System Usability Scale scores were also higher for the chatbot (i.e. 69.7 vs. 67.7), but this difference was not statistically significant. The chatbot took longer to complete but was perceived as conversational, interactive, and intuitive. The online form received favorable comments for its familiar survey-like interface.

CONCLUSION: Our findings demonstrate that a chatbot provided superior engagement, intuitiveness, and interactivity despite increased completion time compared to online forms. Knowledge of patient preferences and barriers will inform future design and development of recommendations and best practice for chatbots for healthcare data collection.

Insomnia is common but severely underreported and undertreated. One possible reason for this problem is the lack of providers in cognitive behavioral therapy for insomnia (CBT-I). To address this we created CBTIweb.org, an online training platform for providers to learn the basics of sleep, assessing insomnia, and CBT-I. The present study assessed the reach of CBTIweb by examining engagement, knowledge acquisition, and perceived acceptability. Participants who registered for CBTIweb self-reported their practice setting and personal characteristics (i.e. degree, profession, licensure status). Knowledge acquisition was assessed with pre- and post-tests, and provider acceptability was assessed via a survey. In the first three months after launching CBTIweb, 2586 providers registered and 624 of these completed the training within three months of registering. Chi-square tests of independence revealed no differences in completion rates by education or profession, though trainees were more likely to initiate and complete treatment than licensed providers. Paired t tests revealed significant knowledge acquisition, and most providers positively rated the website navigation, content, aesthetics, and understanding of core CBT-I skills. This study demonstrated CBTIweb is an effective platform for training health professionals to be minimally proficient in the gold standard treatment for insomnia disorder.

BACKGROUND: While telemedicine has been expanding over the past decade, the COVID-19-related restrictions regarding in-person care have led to unprecedented levels of telemedicine utilization. To the authors' knowledge, no studies to date have quantitatively analyzed both national and regional trends in telemedicine utilization during the pandemic, both of which have key implications for informing health policy.

OBJECTIVE: This study aimed to investigate how trends in telemedicine utilization changed across the course of the COVID-19 pandemic.

METHODS: Using data from doxy.me, the largest free telemedicine platform, and the NIH (National Institutes of Health) Clinical Center, the largest clinical research hospital in the United States, we assessed changes in total telemedicine minutes, new provider registrations, monthly sessions, and average session length from March to November 2020. We also conducted a state-level analysis of how telemedicine expansion differed by region.

RESULTS: National telemedicine utilization peaked in April 2020 at 291 million minutes and stabilized at 200 to 220 million monthly minutes from May to November 2020. Surges were strongest in New England and weakest in the South and West. Greater telemedicine expansion during the COVID-19 pandemic was geographically associated with fewer COVID-19 cases per capita. The nature of telemedicine visits also changed, as the average monthly visits per provider doubled and the average visit length decreased by 60%.

CONCLUSIONS: The COVID-19 pandemic led to an abrupt and subsequently sustained uptick in telemedicine utilization. Regional and institute-level differences in telemedicine utilization should be further investigated to inform policy and procedures for sustaining meaningful telemedicine use in clinical practice.

The COVID-19 pandemic accelerated adoption of telemental health (TMH). Providers with limited TMH experience faced challenges during the rapid switch to remote patient care. We investigated TMH providers' perceptions about remote care one year into the pandemic according to when providers adopted telemedicine (i.e., before vs. after March 2020) and how much of their caseloads were served remotely (i.e., < 50% vs. ≥ 50%). Between February-March 2021, 472 TMH providers completed a cross-sectional, web-based survey that measured perceived benefits and satisfaction with telemedicine, therapeutic alliance, patient-centered communication, eHealth literacy, multicultural counseling self-efficacy, and facilitating factors of using telemedicine. Providers who began using telemedicine before the pandemic reported having better training, task-related therapeutic alliance with patients, and ability to conduct multicultural interventions, assessments, and session management. Providers who served ≥ 50% of their caseload remotely reported greater satisfaction with their practice, stronger beliefs about the benefits of telemedicine, and greater perceived effects of telemedicine on alleviating the impact of COVID-19. There were no differences in reports of patient-centered communication nor eHealth literacy. In conclusion, providers who adopted TMH more recently may require additional training and support to successfully establish a working alliance with their patients, especially with multicultural aspects of care.

Purpose: This study investigated disparities in the uptake of telemedicine and the degree of patient-centeredness of telemedicine consultations among vulnerable patient populations. The focus includes rural adults and adults living with psychological distress and a high risk for chronic obstructive pulmonary disease (COPD). Materials and Methods: In August 2020, a random sample of 932 U.S. adults ≥35 years old with a history of smoking tobacco completed an online survey. Chi-squared analyses were conducted to compare the sociodemographics of participants who did and did not use telemedicine. A series of analysis of variance tests were conducted to examine whether satisfaction with patient-centeredness of telemedicine consultations (i.e., open-endedness, expressed empathy, provider's ability, 5-point Likert scale) differs by rural/urban residence, psychological distress, and COPD risk. Results: About 25% of the sample (n = 240) reported having used telemedicine. Telemedicine use was associated with younger age, Hispanic ethnicity, and moderate-to-high psychological distress, but not rurality. Participants reported high general satisfaction with the patient-centeredness of telemedicine consultations (M = 4.42 ± 0.73). However, high psychological distress and identifying as a current smoker were associated with less satisfaction across all domains. High COPD risk was uniquely associated with less satisfaction in how providers express empathy remotely. Conclusion: Individuals with moderate-to-high psychological distress and a high risk for COPD experience challenges accessing high-quality, patient-centered care via telemedicine. As telemedicine becomes ubiquitous in health care, innovative solutions are needed to overcome barriers that prevent providers from delivering patient-centered care and patients from feeling satisfied with their remote consultations.

Phobias and related anxiety are common and costly mental health disorders. Experts anticipate the prevalence of phobias will increase due to the COVID-19 pandemic. Exposure therapies have been established as effective and reliable treatments for anxiety, including recent innovations in virtual reality-based exposure therapy (VRET). With the recent advent of telemental health (TMH), VRET is poised to become mainstream. The combination of VRET and TMH has the potential to extend provider treatment options and improve patient care experiences. In this narrative review, we describe how recent events have accelerated VRET + TMH, identify barriers to VRET + TMH implementation, and discuss strategies to navigate those barriers.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality, despite evidence there is a high proportion of underdiagnosis. Online screening assessments are low-cost solutions to identify high-risk adults who may benefit from confirmatory screening (ie, spirometry test). Little evidence exists to support whether high-risk adults seek advice after completing COPD screening assessments and from whom. The purpose of this study is to examine how the perceived quality of an online screening assessment influences high-risk adults to seek advice from a healthcare provider or other online resources.

METHODS: Adults without a prior COPD diagnosis (N = 199) completed an online survey that included a computer-tailored assessment programmed with the clinically validated COPD Population Screener (COPD-PS).

RESULTS: An elevated COPD risk score was associated with expectations to talk with a healthcare provider (P < 0.05) or go on the Internet (P < 0.05) to get advice, controlling for statistically significant covariates. Positive perceptions about the quality of the risk score was associated with strengthened expectations to speak with a healthcare provider, but only among high-risk adults (P < 0.01).

CONCLUSIONS: Results of this study support the use of computer-tailored screening assessments as a scalable solution to encourage high-risk adults to learn more about COPD. Strengthened perceptions about the quality of an online COPD screening assessment increased the likelihood that high-risk adults will speak with their healthcare provider about the condition. Implications are discussed for leveraging telehealth solutions, such as conversational agents (ie, chatbots), to disseminate COPD screening assessments and alleviate its underdiagnosis.

TRIAL REGISTRATION: not applicable.