Indiana University-Purdue University Indianapolis (IUPUI) / Due to frequent utilization, high costs, high prevalence, and negative health outcomes, the care of patients managing type 2 diabetes mellitus (T2DM) remains an important focus for providers, payers, and policymakers. The challenges of care delivery, including care fragmentation, reliance on patient self-management behaviors, adherence to care management plans, and frequent medical visits are well-documented in the literature. T2DM management produces numerous clinical data points in the electronic health record (EHR) including laboratory test values and self-reported behaviors. Recency or absence of these data may limit providers’ ability to make effective treatment decisions for care management. Increasingly, the context in which these data are being generated is changing. Specifically, telehealth usage is increasing. Adoption and use of telehealth for outpatient care is part of a broader trend to provide care at-a-distance, which was further accelerated by the COVID-19 pandemic. Despite unknown implications for patients managing T2DM, providers are increasingly using telehealth tools to complement traditional disease management programs and have adapted documentation practices for virtual care settings. Evidence suggests the quality of data documented during telehealth visits differs from that which is documented during traditional in-person visits. EHR data of differential quality could have cascading negative effects on patient healthcare outcomes. The purpose of this dissertation is to examine whether and to what extent levels of EHR data quality are associated with healthcare outcomes and if EHR data quality is improved by using health information technologies. This dissertation includes three studies: 1) a cross-sectional analysis that quantifies the extent to which EHR data are timely, complete, and uniform among patients managing T2DM with and without a history of telehealth use; 2) a panel analysis to examine associations between primary care laboratory test ages (timeliness) and subsequent inpatient hospitalizations and emergency department admissions; and 3) a panel analysis to examine associations between patient portal use and EHR data timeliness.

This study sought to better understand the experiences of individuals with a chronic health condition utilizing telemedicine during the first twelve months of the COVID-19 pandemic. To do this, an online survey was advertised in two private Facebook support groups for individuals with adrenal insufficiency; a chronic health condition that requires frequent communication with healthcare providers. The survey consisted primarily of closed-response questions which examined the demographic data of respondents, their access to healthcare providers, their comfort levels accessing healthcare providers, and the number of times individuals sought healthcare during the first twelve months of the COVID-19 pandemic to try and predict their preference for telemedicine and in-person healthcare visits going forward. Additionally, the survey included open-response questions which allowed for respondents to describe their experience utilizing telemedicine during the first twelve months of the COVID-19 pandemic. Most respondents described their use of telemedicine as being positive but have indicated there are some health circumstances in which telemedicine may not be the best option for them. Additionally, findings indicate that individual's comfort level in visiting their healthcare providers in-person during that first year of the COVID-19 pandemic is a significant predictor of an individual's preference for telehealth. This gives future studies a starting point to investigate the driving social and health factors that shape an individual's perception of risk influencing their level of comfort and predicting their preference of telemedicine or in-person visits for their non-emergency healthcare needs.

BACKGROUND: Telehealth is a healthcare delivery platform that allows for clinicians to deliver care via the phone or computer. The public health restrictions associated with the Covid-19 pandemic have shown how telehealth could be used as a platform to deliver care. With state-wide stay at home orders and the associated suspension of elective medical procedures telehealth rose as an option to deliver care to patients. Prior authors described that telehealth usage increased at the start of the pandemic and then decreased once the reopening processes in several states commenced in the May to June period. Although these studies have provided valuable information regarding telehealth, many of these did not look beyond the June time frame. In addition, the implications from the range of telehealth policies remain largely unexplored. OBJECTIVE: We sought to assess policies and other drivers of telehealth use. In order to achieve this, we described the change in telehealth usage over the year of 2020, identified potential drivers of increased telehealth usage at the patient and policy level, and explored the heterogeneity of state policies. METHODS: We performed a retrospective cohort study of 417,963 de-identified individuals with healthcare visits between December 2019 to December 2020. This data was extracted from HealthJump, which contains Electronic Health Record data sourced from participating members of its network. Visits were labeled telehealth by using CPT billing codes. We explored national and state-level trends in telehealth use, as well as patient-level drivers such as demographics, medical diagnoses, and Covid-19 status. RESULTS: Telehealth usage increased at the onset of the pandemic across the nation, different age groups, and various health diagnoses. The relaxation of state policies led to a decrease in telehealth usage across the nation and individual states but was higher than pre-pandemic conditions. Telehealth was used more by those with conditions deemed “at-high-risk” for Covid-19 as well as medical specialties that were more feasible for the virtual platform. Patients who were Covid-19 positive used telehealth more in the latter part of the year. Patients who were 65 and older did use telehealth, even though it was at a lower volume than the other age group (under 65). CONCLUSION: The Covid-19 pandemic has shown how telehealth can be an effective alternative to in-person visits for medical needs that are elective or non-life-threatening. Although telehealth may not be used in the same capacity as it was during Covid-19, the results show that people are willing to use it and that looking into the future Telehealth can be implemented into the healthcare system.

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Purpose: The primary purpose of this research was to explore individuals born in the millennial generation’s likelihood of using telehealth and virtual office visits as a replacement for face to face provider interactions. The secondary purpose was to examine the feasibility and access of treatable conditions and ailments in a virtual environment. Methods: A literature review exploring millennials and telehealth was performed using various databases with search terms combined to include: ‘millennials*’, ‘telehealth*’, ‘telemed*’, ‘finance*’, ‘primary care*’, ‘healthcare*’, ‘health knowledge*’, ‘literacy*’, ‘education*’, ‘misinformation*’. The data was conformed into tables that synthesized the relationship between the millennial generation and their access to telehealth and virtual office visits. Results: An initial search of literature returned 72 articles that met search criteria. In total, 10 articles were chosen for synthesis and relevance to the topic. After further review, a total of 10 articles were chosen for synthesis and relevance to the topic. The results suggest the use of telehealth as a virtual office visit in place of face to face interaction have limited applications at this time. The severity of conditions used by millennial’s for telehealth ranged from mild symptomatic conditions, such as the common cold, to moderate symptomatic conditions, such as sore throat and gastrointestinal discomfort. Millennial populations are more likely to use telehealth and virtual office visits based on their increased proficiency and use of technology; however this does not translate into actual use of technology for health-related conditions. Millennials likelihood of embracing telehealth and virtual office visits is related to convenience and timeliness of care, as well as trust in the provider established through web-based reviews and ratings offered by other telehealth users. Cost is not as beneficial as originally anticipated. Factors regarding safety and privacy through mobile applications and online portals are untested.

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Deaths from opioid overdose have increased dramatically in the past decade, representing an epidemic in the United States. For individuals with opioid use disorder (OUD), agonist medications such as methadone and buprenorphine represent an evidence-based treatment that has been shown to reduce opioid-related morbidity and mortality. Historically, the provision of buprenorphine treatment in office-based settings has relied on frequent in-person contact, which influenced patients’ access to and retention in care. However, in response to the COVID-19 pandemic, providers of office-based buprenorphine treatment rapidly adapted their care processes, increasingly relying on telemedicine visits. This dissertation employed mixed methods to study the implementation and effectiveness of telemedicine in office-based buprenorphine treatment provided in safety-net settings, or those that provide health services to patients regardless of their ability to pay. Qualitative methods were used to explore provider and patient experiences with the use of telemedicine in an office-based buprenorphine treatment clinic associated with an academic safety-net hospital, while quantitative methods were used to examine the effects of telemedicine adoption on outcomes for patients with OUD attending federally-qualified health centers (FQHCs) in Massachusetts. Results from provider interviews indicated the implementation of telemedicine in office-based buprenorphine treatment precipitated openness to more flexibility in care practices, though providers expressed concerns regarding telemedicine and related adaptations that centered around patient safety. Results from patient interviews indicated telemedicine enabled engagement in care, though patients differed in their views on: 1) the appropriateness of telemedicine based on one’s stage of recovery, 2) how telemedicine impacted their relationships with providers, and 3) their preferences for telemedicine visits moving forward. Results from both patient and provider interviews indicated safety-net patient populations experienced unique challenges when using telemedicine, particularly due to difficulties with technology and privacy. Finally, results from the quasi-experimental study of telemedicine adoption across a network of FQHCs indicated it was associated with: 1) increases in all-cause and OUD-related outpatient care engagement, 2) increases in retail buprenorphine fills and days supplied, and 3) either no changes or decreases in all-cause and OUD-related emergency department visits and inpatient admissions. These findings suggest telemedicine has the potential to improve patients’ engagement in office-based buprenorphine treatment while not compromising safety; however, qualitative data emphasizes the perceived benefits of hybrid, patient-centered approaches to care, particularly in safety-net settings. Overall, results of this dissertation support the maintenance of changes to policy and practice that facilitate the use of telemedicine in office-based buprenorphine treatment beyond the COVID-19 public health emergency. / 2025-01-03T00:00:00Z

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that presents many challenges for parents and providers while impacting a child's developmental trajectory across several domains, including disruptive behaviors. Unfortunately, due to limited access and affordability of care, especially during the pandemic or other situations that require people to stay at home, in-person services are not always feasible. Rural or underserved communities may face additional barriers, such as geographic isolation and lack of ASD resources. Accessibility of ASD treatment may be expanded through telehealth supports, such as mobile applications. When implementing these supports for autistic children, decreasing child problem behaviors while improving parent stress, knowledge, and competence is crucial. The current study investigated the feasibility and preliminary efficacy of a behavior consultation mobile application, Treks, to improve telehealth support for 26 parents (male = 2) of autistic children (3-13 years). Participants were randomly assigned to a one-session telehealth consultation with 1) the enhancement of the Treks app over the course of one month (TH) or 2) with access to mobile resources comparable to Treks for one month (CC). They were then administered measures at baseline, pre-Treks, and post-Treks to assess changes in parenting stress, knowledge, competence, and child behaviors as well as feasibility metrics. Results indicated that the mobile app was received positively across groups, showing significant improvement in participants enrolled in the TH group from pre- to post-Treks on parenting and child outcomes, in addition to moderate to high satisfaction. Future directions should examine the use of mobile supports to supplement parent training consultations for caregivers of autistic children who present with a range of behavioral difficulties. / Doctor of Philosophy / Autism spectrum disorder (ASD) presents with many challenges for parents and providers. Unfortunately, due to limited access and affordability of care, especially during the pandemic or other situations that require people to stay at home, in-person services are not always feasible. Rural or underserved communities may face additional barriers, such as geographic isolation and lack of ASD resources. Accessibility of ASD treatment can include telehealth (e.g., mobile applications), and should focus on decreasing child problem behaviors while improving parent stress, knowledge, and competence. The current study investigated the feasibility and preliminary efficacy of a behavior consultation mobile application, known as Treks, to improve telehealth support for 26 parents of autistic children (3-13 years). Participants were randomly assigned to a one-session telehealth consultation with access to 1) Treks for one month (TH) or 2) mobile resources comparable to Treks for one month (CC). They were then administered measures at baseline, pre-Treks, and post-Treks to assess changes in parenting stress, knowledge, competence, and child behaviors as well as feasibility. Results indicated that the mobile app was received positively across groups, showing significant improvement in participants enrolled in the TH group from pre- to post-Treks on parenting and child outcomes, in addition to moderate to high satisfaction. Future research should examine the use of mobile apps to supplement parent training for caregivers of autistic children who present with a range of behavioral difficulties.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that presents many challenges for parents and service providers. Unfortunately, there are limited examples of parent-mediated interventions for parents of children with ASD that can help manage behavioral problems, especially those that can be implemented in both urban and rural communities. COMPASS for Hope (C-HOPE) is an 8-week parent-mediated intervention that enhances parent knowledge, behavior management skills, and supportive strategies. Telehealth-based interventions can be especially effective for rural communities due to its ability to address common barriers of geographic location and lack of resources. When implementing this intervention, the ability to decrease child problem behaviors as well as increase parental activation, self-management, perceived competence, and knowledge are essential to determine the efficacy of this treatment. The purpose of the current study is to evaluate these outcomes in the implementation of C-HOPE via telehealth in rural versus urban communities. 20 parents with children from 3-12 years of age with a diagnosis of ASD were sampled from two rural sites and two urban sites in Kentucky. Few differences were noted between the participants in the rural versus urban group at pre-treatment. Following C-HOPE, in the urban area, there were significant treatment effects in parent knowledge outcomes. In the rural areas, a significant effect was found in change of parent self-management skills of toileting issues. Future directions for telehealth treatments for this population are discussed. / M.S. / ASD is a developmental disorder that presents many challenges for parents and providers. Unfortunately, there are limited behavioral treatment options for parents of children with ASD, especially those that can be utilized in both urban and rural communities. COMPASS for Hope (C-HOPE) is a parent intervention that improves parent knowledge, management, and supportive strategies. Technology-based interventions can be especially effective for rural communities due to its ability to address barriers of geographic location and lack of resources. In this intervention, the ability to decrease child problem behaviors as well as increase parental activation, self-management, competence, and knowledge are essential for this treatment to be effective. The current study evaluates these outcomes in C-HOPE using technology in rural versus urban communities. 20 parents with children with ASD, ranging from 3-12 years of age, were sampled from rural and urban areas in Kentucky. Few differences were noted between the participants in the rural versus urban group before treatment. After treatment, in the urban area, there were significant effects in parent knowledge outcomes. In the rural areas, a significant effect was found in change of parent self-management skills. Future directions for technology treatments for this population are discussed.