According to the Association of American Medical Colleges, the primary care workforce shortage in 2025 will exceed 46,000 primary care physicians. Healthcare business leaders in Gwinnett County, Georgia have not evaluated the advantages and disadvantages of telemedicine (TM) to mitigate the workforce shortage. The purpose of this qualitative descriptive study was to determine factors primary care physician administrators consider when deciding to implement TM as a potential solution for the growing physician shortage. A purposive sample of 20 primary care physician administrators located in Gwinnett County, Georgia was drawn. The theory of disruptive technology was the conceptual framework. Data collected stemmed from semistructured interviews with each participant and review of organizational plans and workflow documents. Data were recorded, transcribed, and coded to develop themes. Three themes morphed from the study: TM awareness and education, TM cost and reimbursement, and TM implementation and utilization. Results indicated that awareness and education of leaders toward TM requires improvement, costs, and reimbursement were variables for deciding to implement or not implement TM, and TM implementation requires knowing the appropriate use of TM. The implications for positive social change include the potential for primary care physician administrators to positively influence the healthcare workforce shortage by adding flexibility to manage patient workflow with TM. Additionally, the potential for physician administrators to utilize TM for healthcare access, creating savings in transportation, energy consumption, and resource optimization, may provide better access to hard-to-reach populations.

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Introduction: The objective of this study was to measure virtually-based objective structured clinical exam (OSCE) pass rates of student pharmacists who received remote, synchronous instruction on medication reconciliation compared with OSCE pass rates from the previous class, who received face to face synchronous instruction and OSCEs. The secondary objective was to measure student perceptions of remote instruction and OSCE preparation. Materials and Methods: Second year student pharmacists attended four online preparatory labs to learn and practice the process of performing a medication reconciliation. A virtually-based OSCE was used to assess student competency of identifying the primary or life-threatening medication related problem (MRP). Failing to identify the MRP represented a “kill point” and an automatic failing grade. A brief 10-item survey designed to measure student perceptions was sent to all participants post OSCE. Results: Seventy-seven students completed the OSCE and the overall pass rates were similar between the 2020 and 2019 class years (97% vs 94%, respectively; p = 0.24). Survey responses showed students lacked confidence, preferred face-to-face learning rather than online and most described their remote environments as not conducive to learning. Conclusion: Online instruction and assessment was at least as effective as traditional face-to-face methods. however the virtual-based platform was not preferred by learners.

Hjärtsvikt är ett kliniskt syndrom som kan innebära stor påverkan på den drabbades hälsorelaterade livskvalitet och livssituation genom funktionsnedsättande symtom och stort vårdbehov. Tillståndet har hög dödlighet och ökar med en åldrande befolkning även om behandlingen förbättrats. Telemedeicin implementeras i hjärtsviktsvården på flera håll i Sverige och kan med fördel integreras i vården enligt gällande internationella riktlinjer. Syftet var att undersöka hur patienter med hjärtsvikt påverkas vid användning av olika former av telemedicin avseende livskvalitet och patientens livssituation. Metoden var litteraturöversikt med ett systematiskt arbetssätt. Sökningar utfördes i databaserna PubMed och Cinahl. Artiklarna kvalitetsgranskades utifrån Sophiahemmet Högskolas bedömningsunderlag. 15 artiklar publicerade 2013-2021 inkluderades från dessa sökningar. En integrerad analys av artiklarna utfördes. Resultatet visade att användning av telemedicin vid hjärtsvikt kan påverka livskvaliteten och patienternas livssituation. De kategorier som framträdde i resultatet var påverkan på livskvalitet utifrån hälsa, stöd till förändrat behov av sjukvård, support till egna handlingar och stöd tll förändringar i psykisk hälsa. Telemedicin påverkade den hälsorelaterade livskvaliteten positivt och kunde ge stöd till förändrat behov av sjukvård. Telemedicin kunde också ge support till egna handlingar och stöd till förändrad psykisk hälsa. Olika former av telemedicin hade använts enskilt eller som tillägg till andra interventioner. Slutsatsen är att telemedicin vid hjärtsvikt kan påverka patienternas hälsorelaterade livskvalitet och livssituation positivt. Vidare forskning kring vilka former av telemedicin som har positiv påverkan behövs samt vilka interventioner som med fördel kan kombineras. / Heart failure is a clinical syndrome that may have a major impact on the affected´s health related quality of life (HRqOL) and life in general through disabling symptoms and a substantial need for helathcare. Even though treatment has improved, the condition has high mortality rate and is increasing with an aging population. Telemedicine is implemented in heart failure care in several locations in Sweden and can advantageously be integrated into care according to international guidelines. The aim of this study was to scrutinize how patients with heart failure are affected when using various types of telemedicine regarding quality of life and life situation. The method was a literature review with a systematic approach. Literature search was conducted in the databases PubMed and Cinahl. The quality of the articles was reviewed according to Sophiahemmet University´s assessment documents. A total of 15 articles published between 2013-2021 were eventually included in the study. An integrated analysis of the articles was performed. The results showed that the use of telemedicine in heart failure can affect quality of life and the patient´s life situation. The categories that appeared in the results were impact on quality of life based on health, support for changing needs for healthcare, support for own actions and support for changes in mental health. Telemedicine had positive impact on HRqOL and supported changing needs for healthcare. Telemedicine could provide support for own actions and support for changed mental health. Various forms of telemedicine had been used alone or combined with other interventions.  The conclusion is that telemedicine in heart failure can positively affect the patients´ HRqOL and life situation. Further research on which forms of telemedicne have a positive impact is needed and which interventions can be advantageously combined.

Despite legal and technological advances, women still face barriers to abortion care in legally restricted or low-resource settings. The advent of medication abortion using misoprostol with or without mifepristone, has enabled women to self-manage their abortions outside of the formal healthcare system. Self-managed abortions are often assisted by telemedicine services, which provide women with evidence-based guidance on managing the abortion process on their own. This thesis explores two separate abortion telemedicine services operating in legally restricted and/or low resource settings – a global online telemedicine service and an abortion support hotline in Venezuela – and evaluates the outcomes associated with each. By interviewing counsellors at a Venezuelan abortion support hotline and the women who used the service, we gained a stronger understanding of the hotline’s successes, barriers, and areas for improvement. We conclude that abortion telemedicine services provide effective and acceptable care, in general, and we recommend greater access to misoprostol in Venezuela.

[pt] A dissertação tem como objeto a análise do consentimento informado do paciente no âmbito da telemedicina, especialmente na relação médico-paciente realizada em estabelecimento hospitalares. Nesse sentido, são destacadas as modalidades da telemedicina com o escopo de identificar e atribuir a responsabilidade civil pela violação do consentimento informado do paciente em cada categoria, com base nas normas deontológicas e na legislação pertinente. Com efeito, a dissertação buscará responder os seguintes questionamentos: (a) como respeitar o consentimento informado do paciente na seara da telemedicina? (b) como deve ser efetivado o termo de consentimento informado em cada modalidade da telemedicina? (c) como imputar a responsabilidade civil na relação médico-paciente oriunda da violação do consentimento informado no campo da telemedicina? (d) como provar o consentimento do paciente no âmbito da telemedicina? Para tanto, analisa-se a evolução do consentimento informado do paciente, chegando-se a conclusão de que a autodeterminação é parte integrante da dignidade humana e deve ser respeitada na relação médico-paciente, sob pena de ser imputada a respectiva responsabilidade civil. Nessa toada, discorre-se sobre o desenvolvimento do atendimento médico realizado à distância, bem como são analisadas decisões judiciais a respeito do tema a fim de demonstrar as dificuldades concernentes à consumação do consentimento informado do paciente no âmbito da telemedicina. Por conseguinte, são apresentadas proposições para inclusão no termo de consentimento livre e esclarecido com o escopo de facilitar a compreensão do paciente no atendimento telepresencial e possibilitar a concretização do consentimento informado. Enfim, considerando a dificuldade na produção probatória relacionada ao consentimento informado do paciente, é apresentada uma recomendação que visa contribuir com o aperfeiçoamento da relação médico-paciente no campo da telemedicina. / [en] The dissertation has as its object the analysis of the patient s informed consent in the context of Telemedicine, especially in the doctor-patient relationship carried out in hospitals. In this sense, it is intended to discuss the modalities of telemedicine, identifying and attributing civil liability for the violation of the patient s informed consent in each category, based on deontological norms and on the institutes of the Consumer Defense Code. Consequently, the dissertation will seek to answer the following questions: (a) how to respect the informed consent of the patient in the field of telemedicine? (b) how should the informed consent form be implemented in each modality of telemedicine? (c) how to impute civil liability in the doctor-patient relationship arising from the violation of consent in the field of telemedicine? (d) how to prove the patient s consent in the context of telemedicine? To this end, the evolution of the patient s informed consent is analyzed, reaching the conclusion that self-determination is an integral part of human dignity and must be respected in the doctor-patient relationship, under penalty of being imputed the respective civil liability. In this sense, the development of remote medical care is discussed, as well as judicial decisions on the subject are analyzed in order to demonstrate the difficulties concerning the consummation of the patient s informed consent in the context of telemedicine. Indeed, propositions are presented for inclusion in the free and informed consent form with the aim of facilitating the patient s understanding in telepresence care and enabling the implementation of informed consent. At the end, considering the difficulty in producing evidence related to the patient s informed consent, a recommendation is presented that aims to contribute to the improvement of the doctor-patient relationship in the field of telemedicine.

Bakgrund   I takt med samhällets digitalisering har telemedicin, vård på distans, kommit att spela en allt mer framträdande roll inom hälso-och sjukvården. Inom ramen för det digitala kan patienter numera uppsöka samt erhålla vård från sina egna hem. Den ökade tillgängligheten som telemedicinen för med sig kan fostra en mer aktiv patientroll inom vilken egenvården är av särskild betydelse. Lärdomar kan tas från patienter som använt sig av telemedicinska tjänster och genom att utforska deras upplevelser kan möjligheter och hinder identifieras.  SyfteSyftet var att beskriva patienters upplevelser av egenvård vid användning av telemedicin. Metod Denna studie är utförd som en litteraturöversikt och baserade sig på 16 relevanta vetenskapliga artiklar med en kvalitativ ansats. Artiklarna har med olika sökordskombinationer valts ut från databaserna PubMed och CINAHL. De valda artiklarna kvalitetsgranskades enligt Sophiahemmet högskolas bedömningsinstrument varpå en integrerad innehållsanalys utfördes. Resultatartiklarna delades in i tre kategorier med sex tillhörande underkategorier.     Resultat Resultatet delades in i tre kategorier; egenvårdsbehov, egenvårdskapacitet samt egenvårdsbrist. Den första kategorin handlar om patienters upplevelser av autonomi och tillgänglighet. Den andra kategorin behandlar patienters nya roll samt upplevelser av delaktighet. Den tredje kategorin behandlar aspekterna relation och partnerskap.   Slutsats  Denna studie belyser hur patienter ser både för- och nackdelar med telemedicin. Patienter upplever att telemedicin i mångt och mycket har kapacitet att förstärka deras möjligheter till egenvård och delaktighet men att det finns brister. Telemedicinen är till för alla men förutsätter ett visst krav på tekniskt kunnande samt en vilja till förändring vilket riskerar att utelämna patienter som inte vill eller har möjlighet. Därmed bör lärdom tas från patienternas erfarenheter för att på så sätt använda telemedicinen som ett verktyg för att bidra till en god och jämlik hälso- och sjukvård där alla inkluderas.

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Medical record systems are used whenever caregiving is practiced. The medical records serve an important role in establishing patient safety. It is not possible to prevent honest-but-curious doctors from accessing records since it is legally required to allow doctors to access health records for emergency cases. However, it is possible to log accesses to records and mitigate malicious behaviour through rate limiting. Nevertheless, many of the records systems today are lacking good authentication, logging and auditing and existing proposals for securing medical records systems focus on the context of multiple different healthcare providers. In this thesis, an architecture for an electronic health records system for a telemedicine provider is designed. The architecture is based on several requirements from both the legal perspective and general security conventions, but also from a doctor’s perspective. Unlike the legal and general security conventions perspective, doctor requirements are more functionality and usability concerns rather than security concerns. The architecture is evaluated based on two main threat models and one secondary threat model, i.e. insider adversaries. Almost all requirements are satisfied by the solution design, but the two main threat models can not be entirely mitigated. It is found that confidentiality can be violated by the two main threat models, but the impact is heavily limited through audit logging and rate limiting. / Journalsystem är en central del inom vården och patientjournaler har en stor roll i att uppnå bra patientsäkerhet. Det är inte möjligt att förhindra läkare från att läsa särskilda journaler eftersom läkare behöver tillgång till journaler vid nödsituationer. Däremot går det att logga läkarnas handlingar och begränsa ondsint beteende. Trots det saknar många av dagens journalsystem bra metoder för autentisering, loggning och granskning. Befintliga förslag på att säkra journalsystemen fokuserar på sammanhang där flera olika vårdgivare är involverade. I den här rapporten presenteras en arkitektur för ett patientjournalsystem till en telemedicinsk leverantör. Arkitekturen utgår från flertalet krav baserade på både ett legalt perspektiv och generella säkerhetskonventioner, men även läkares perspektiv. Arkitekturen är evaluerad baserat på två huvudsakliga hotmodeller och en sekundär hotmodell. Arkitekturen uppfyller så gott som alla krav, men de två huvudsakliga hotmodellerna kan inte mitigeras helt och hållet. De två huvudsakliga hotmodellerna kan bryta sekretessen, men genom flödesbegränsning och granskning av loggar begränsas påverkan.