LAUSR

Study Objectives: To explore United States (US)-based emergency medicine (EM) physicians’ perspectives with providing telehealth during the COVID-19 pandemic, with a particular focus on meeting the needs of older (>64 years old) EM patients who may have unique challenges with technology use and increased vulnerability to COVID-19. Methods: We used purposive sampling through social media and listservs to recruit emergency physicians, from all geographic regions and practice settings, who cared for older patients during the pandemic. We conducted 30-minute semi-structured interviews and offered incentives for participation. Initial interview questions elicited general experiences with telehealth during the pandemic, while later questions focused on special considerations for older patients. Interviews were recorded, transcribed and de-identified. We created a codebook a priori, double-coded the interview transcripts, and used framework matrix analyses to identify themes and subthemes. Results: We interviewed from July to November 2020. Participating physicians (n=15;academic 10/15, community 5/15) practiced in all US regions. Practice locations included metro (7/15), suburban (6/15), and rural areas (2/15). Physicians reported using telehealth in the outpatient setting and within the emergency department (ED), especially during personal protective equipment (PPE) shortages. Several themes emerged: (1) telehealth as a public health tool, (2) its suitability for EM patients, (3) special considerations for older patients, and (4) the future of telehealth. Physicians noted that telehealth was a valuable public health tool, providing access to accurate, timely information about COVID-19. This assistance was considered integral given changing guidance on testing, hospital capacity concerns necessitating thoughtful triage, and limited availability of PPE. Physicians noted that telehealth improved access to care for EM patients who lived in rural communities, had mental health concerns or mobility challenges, or received home hospital care. Most expressed that telehealth was suitable for low acuity EM complaints, but those with chest or abdominal pain, as well as critical patients, required in-person care to facilitate rapid diagnosis, testing, and interventions. They considered virtual care convenient, efficient and useful for establishing rapport with older patients and caregivers (including for end-of-life conversations). Emergency physicians indicated that telehealth would be beneficial in the future as a complementary method of care rather than a complete replacement of in-person ED visits if reimbursement policies and multi-state licensure concerns were addressed. Conclusions: Emergency physicians indicated that telehealth should be integrated into health care delivery as a complementary tool to traditional in-person EM care as it was integral to providing public health information, in addition to low acuity complaint diagnosis and treatment. Although technological barriers existed, many older adults could access and benefit from virtual care.