This research proposal is in response to AHRQ (NOT-HS-16-009) and examines the quality and safety impacts of real-time patient-provider video and telephone visits, interactive health information technology (IT) tools with potential to engage patients through convenient health care access. Telemedicine can offer patients the choice to access a provider visit without the obstacles of securing transportation, arranging time-off from work or care-giving, or spending time in a waiting-room. Even as American patients are increasingly purchasing internet-based telemedicine visits from third party services without in-person facilities, gaps remain in the scientific evidence about patient adoption of telemedicine for primary care encounters (compared with in-person visits). This study will examine a 2016 health IT implementation offering patient - initiated primary care telemedicine encounters through the patient portal of an integrated healthcare delivery system. All patients scheduling an appointment with a primary care provider through the portal (website and mobile application) choose directly between a traditional in -person visit and a telemedicine visit, either by video or telephone. Over a five year study period (2016 -2020), we will examine a large sample of patient-scheduled telemedicine appointments, including over 50,000 video visits and 500,000 telephone visits, compared with millions of patient-scheduled in-person visits. Using patient surveys (N=1,500) and stakeholder key informant interviews, we will examine the experiences of telemedicine users and decision-makers, including technology usability, convenience, and patient-reported outcomes. In the study setting, this novel patient telemedicine access is fully integrate d with patients? own existing health care providers and comprehensive electronic health record (EHR). We will examine patient clinical concerns and access measures associated with the choice of a telemedicine encounter compared with in-person encounters (Aim 1), and the quality and safety of the telemedicine encounters through guideline-recommended health care processes (prescribing and ordering), follow-up visits, and events ( emergency department visits) (Aim 2). We will test the hypotheses that care processes and short-term event rates for patient-initiated telemedicine encounters will not be worse than for patient-initiated in-person visits (non-inferiority hypothesis), while accounting for patient engagement, recent changes in health status, case-mix, cost-sharing for in-person visits, internet access, and patient demographic and socio-economic characteristics. By examining an early adopter of the technologies, and a large and diverse patient population, this project has the potential to provide timely evidence to inform emerging telehealth policies, technology adoption decisions, and real world use by patients and clinicians.
Real-time patient-provider video and telephone visits are an interactive technology with potential to engage patients through convenient health care access. Our research questions about the impact of patient- initiated telemedicine encounters that are well-integrated with existing electronic health records and health care providers, are broadly applicable given high patient interest in telemedicine and the need for rigorous research across the broad clinical concerns addressed in primary care.