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      Shared Decision Making in the Era of Telehealth: Implications for Practice and Research

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          Since its emergence in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the coronavirus disease 2019 (COVID-19), has infected over 14 million individuals worldwide. 1 This unprecedented pandemic has forced clinicians to rethink how health care can be delivered to minimize the risk of disease transmission and promote patient safety while still meeting the general health needs of patients. As a result, telehealth visits (either by telephone or telehealth audio and video platforms) have become the preferred mode for many encounters. 2 It seems increasingly likely that such telehealth visits will persist long after the pandemic has abated, resulting in the need to assess the impact of this change on clinical care and patient-centered research. Shared decision making (SDM) refers to the process by which clinicians and patients work through clinical problems together to arrive at decisions that make emotional, practical, and intellectual sense for the patient. 3 This process is highly dependent on clear and unhurried communication. Effective SDM is essential to patient-centered care and is recommended by many professional societies when confronted with particular medical decisions. 4 However, how to best implement SDM remains unknown. Strategies that rely on decision aids or patient-education materials have been developed, but uptake of these tools remains low in clinical practice. What does the current shift toward telehealth in care delivery mean for SDM? Can technology be leveraged to facilitate effective SDM? Will this shift minimize or exacerbate health care disparities? What does this change mean for how researchers study SDM? In this commentary, we explore these questions from the perspectives of clinicians and researchers. Historical Perspective Telehealth encompasses multiple visit modalities, including synchronous live video, a live telephone call, asynchronous interactions on web-based platforms, and remote patient monitoring. 5,6 Traditionally, it has been used in attempts to minimize disparities in access to care for rural and underserved populations. Until recently, state legislation and state Medicaid programs restricted telehealth delivery through the services that can be provided, provisions for reimbursement, the location and licensure of the clinician providing services, and the physical location of the patient (requiring patients to travel to a designated telehealth-enabled center). 5,6 However, due to the current pandemic, the Federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and an expansion of Section 1135 of the Social Security Act relaxes provisions on originating sites and eligible services for reimbursement, allowing clinicians to reach patients across a broader context. 7 Relaxation of rigid telehealth guidelines means patients can now receive routine care from their home. Expanding Telehealth Delivery The new flexibility of telehealth options has led to a surge in the number of telehealth visits during COVID-19. Prior to COVID-19, approximately 17,000 Medicare patients received a telehealth service weekly; in the last week of April 2020, that rose to about 1.7 million. 8 The scope of telehealth can be wide, reaching more patients overall and of diverse backgrounds and yielding the promise of achieving SDM broadly. Yet, there is significant variation in the method of delivery (phone or video); such variations have implications for SDM. Research has shown that achieving SDM over a phone call is feasible, 9 but also may preclude use of any ancillary materials the clinician would use in an in-person encounter. Alternately, use of videoconferencing technology allows the clinician and patient to see each other. This medium provides the possibility for nonverbal cues both to be expressed and addressed (e.g., facial cues suggesting confusion), and offers an opportunity to show visual aids designed to promote patient comprehension via “screen sharing,” which may lead to increased SDM. However, drawbacks to videoconferencing exist. Clinicians may have to learn new online platforms, obtain necessary equipment (e.g., webcams), learn institutional protocols relevant to patient privacy and data security, and alter their documentation to ensure reimbursement coverage. From the patient’s perspective, such technological solutions require varying degrees of access to technology, technical acumen, and potential out of pocket costs. Furthermore, if online platforms are used, they need both to connect to the internet and to have access to a stable internet connection may preclude some patients from benefitting from a telehealth encounter. Use of telehealth can also introduce communication challenges due to pauses or interruptions caused by poor internet connections, potentially limiting conversations and likely SDM. The adoption of telehealth solutions further introduced additional issues regarding potential breaches in data security and privacy. 10 Patients’ level of awareness and concern of these risks will vary, as will their willingness to engage in telehealth due to these potential risks. It is imperative that clinicians and other health care staff are aware of institutional data security and privacy measures to ensure they can accurately address patient concerns. Despite these challenges, trusting relationships built between patient and clinician are shown to occur through telephone alone; 9 videoconferencing software is only expected to further increase these relationships. Impact on Health Disparities Although telehealth initially was designed to reduce disparities, 7 the current reliance on personal technological devices could introduce additional disparity. While 85% of Americans have a smartphone and 75% own a computer, 11 a significant number of patients may lack internet access, as well as access to necessary tools to engage in telehealth. Similarly, some patients may lack familiarity with technology needed to execute these visits (e.g., downloading apps). There also may be patients who are not comfortable with telehealth, do not have a private space to have a telehealth visit, or prefer to wait until they are able to be seen in person. The potential disparities introduced by telehealth are likely to be associated with age, digital readiness, income, education level, and race. 2 Some of these patient characteristics are already associated with low rates of achieving SDM in clinical visits. 12 Racial minorities have been shown to have lower rates of SDM in clinical studies, suggesting that telehealth could exacerbate disparities within these populations in terms of SDM. 12 Conversely, telehealth could help reduce disparities in some circumstances. The resources required for in-person visits are not trivial—patients need the means to travel to appointments, the ability to take time away from other duties (work, caregiving, etc.), and sufficient health and mobility to travel. Telehealth may offer both a less time-intensive and geographically restricted option for care. It may allow access to appointments that would otherwise not happen without technology (e.g., for those living in rural communities), may allow less time in waiting rooms/traveling, and may provide a more comfortable experience for patients (receiving care at home). Impact of Clinical Research Translating in-person SDM clinical research to telehealth is possible but will require adaptations. For optimal observation and assessment of SDM, recording telehealth interactions is recommended. Requiring recording of telehealth visits introduces challenges such as liability of platforms previously unused and storage management of the recordings. Furthermore, not all videoconferencing platforms being used to provide telehealth have adequate recording capabilities. It is possible to mimic typical in-person recording of clinical visits by setting up a recorder to view or listen into the telehealth videoconferencing screen or phone call; however, video quality may be reduced. Research teams will need to determine which option is the most feasible based on their unique setting and research needs, while maintaining HIPAA compliance. Despite new considerations in maintaining personal health information, there are potential benefits to SDM clinical research in the telehealth setting. One benefit may be the ability to reduce experimenter bias during virtual research visits. During in-person SDM research, the researcher may remain present in the clinical exam room for note-taking or recording operation, potentially introducing experimenter bias through subtle, inadvertent behaviors. 13 Via telehealth, researchers may be able to turn off their video during the virtual visit, which may reduce the influence their presence has on data collection for SDM clinical research. Conclusion Use of telehealth in the medical field has increased rapidly as patients access health care during the COVID-19 pandemic. There are multiple benefits and drawbacks to transferring such a large portion of in-person health care visits to virtual visits. Drawbacks are mainly related to access to technology and having technological acumen; benefits include greater access to visits for researchers and the ability to record patient-clinician interaction with less experimenter bias. SDM is highly dependent on clear and unhurried communication between patient and clinician. The shift toward telehealth in care delivery means placing additional responsibility on clinicians to ensure that clear communication occurs. Such responsibility may be easier addressed via the use of videoconferencing software (as opposed to telephone interactions) due to the ability to recognize facial cues and to share resources in real-time via screen sharing. Any current studies that are researching SDM in a clinical setting are almost certainly forced to switch to telehealth due to the current pandemic, which presents a unique opportunity to expand the understanding of achieving SDM in multiple capacities. It remains unclear whether a shift to the use of telehealth encounters may minimize or exacerbate health care disparities and it is important to expand research in this area. Although the COVID-19 pandemic was unprecedented, it may be useful in expanding the understanding of SDM in the context of telehealth and ultimately help provide better care for patients during times when they cannot be physically present with their clinicians.

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          Shared decision making about screening and chemoprevention. a suggested approach from the U.S. Preventive Services Task Force.

          Shared decision making is a process in which patients are involved as active partners with the clinician in clarifying acceptable medical options and in choosing a preferred course of clinical care. Shared decision making offers a way of individualizing recommendations, according to patients' special needs and preferences, when some patients may benefit from an intervention but others may not. This paper clarifies how the U.S. Preventive Services Task Force (USPSTF) envisions the application of shared decision making in the execution of screening and chemoprevention. Unlike conventional USPSTF reports, this paper is neither a systematic review nor a formal recommendation. Instead, it is a concept paper that includes a commentary on the current thinking and evidence regarding shared decision making. Although the USPSTF does not endorse a specific style of decision making, it does encourage informed and joint decisions. This means that patients should be informed about preventive services before they are performed, and that the patient-clinician partnership is central to decision making. The USPSTF suggests that clinicians inform patients about preventive services for which there is clear evidence of net benefit, and, if time permits, about other services with high visibility or special individual importance. Clinicians should make sure that balanced, evidence-based information about the service (including the potential benefits and harms, alternatives, and uncertainties) is available to the patient if needed. For preventive services for which the balance of potential benefits and harms is a close call, or for which the evidence is insufficient to guide a decision for or against screening, clinicians should additionally assist patients in determining whether individual characteristics and personal preferences favor performing or not performing the preventive service. The USPSTF believes that clinicians generally have no obligation to initiate discussion about services that have either no benefit or net harm. Nonetheless, clinicians should be prepared to explain why these services are discouraged and should consider a proactive discussion for services with high visibility or special individual importance or for services for which new evidence has prompted withdrawal of previous recommendations.
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            Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic

            The coronavirus crisis exposes disparities in access to care for vulnerable populations, particularly with respect to telemedicine. There is, however, an opportunity, as payers and providers are temporarily embracing expanded use of video visits, to establish practices that will mitigate inequities now and prevent future disruption of chronic disease management.
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              For telehealth to succeed, privacy and security risks must be identified and addressed.

              The success of telehealth could be undermined if serious privacy and security risks are not addressed. For example, sensors that are located in a patient's home or that interface with the patient's body to detect safety issues or medical emergencies may inadvertently transmit sensitive information about household activities. Similarly, routine data transmissions from an app or medical device, such as an insulin pump, may be shared with third-party advertisers. Without adequate security and privacy protections for underlying telehealth data and systems, providers and patients will lack trust in the use of telehealth solutions. Although some federal and state guidelines for telehealth security and privacy have been established, many gaps remain. No federal agency currently has authority to enact privacy and security requirements to cover the telehealth ecosystem. This article examines privacy risks and security threats to telehealth applications and summarizes the extent to which technical controls and federal law adequately address these risks. We argue for a comprehensive federal regulatory framework for telehealth, developed and enforced by a single federal entity, the Federal Trade Commission, to bolster trust and fully realize the benefits of telehealth.

                Author and article information

                MDM Policy Pract
                MDM Policy Pract
                MDM Policy & Practice
                SAGE Publications (Sage CA: Los Angeles, CA )
                7 December 2020
                Jul-Dec 2020
                : 5
                : 2
                Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
                Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
                Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
                Department of Medicine, US Department of Veterans Affairs, Nashville, Tennessee
                Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
                Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
                Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
                Department of Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
                Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
                Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, Utah
                Author notes
                Elissa M. Ozanne, Department of Population Health Sciences, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84132-2101, USA ( elissa.ozanne@ 123456hsc.utah.edu ).
                © The Author(s) 2020

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                Funded by: American Heart Association, FundRef https://doi.org/10.13039/100000968;
                Funded by: Patient-Centered Outcomes Research Institute, FundRef https://doi.org/10.13039/100006093;
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                July-December 2020


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