Background: Telemedicine has the potential to remove geographic and temporal obstacles to health care access. Whether and how telemedicine can increase health care access for underserved populations remains an open question. To address this issue, we integrated facilitated telemedicine encounters for the management of hepatitis C virus (HCV), a highly prevalent condition among people with opioid use disorder (OUD), into opioid treatment programs (OTPs). In New York State, OTPs are methadone-dispensing centers that provide patient-centered, evidence-based treatment for OUD. We investigated the integration and impact of facilitated telemedicine into OTP workflows in these settings. Objective: This study aims to understand OTP staff experiences with integrating facilitated telemedicine for HCV treatment into OTPs, including best practices and lessons learned. Methods: We conducted semistructured interviews with 45 OTP staff members (13 clinical, 12 administrative, 6 physicians, and 14 support staff members) at least one year after the implementation of facilitated telemedicine for HCV management. We used hermeneutic phenomenological analysis to understand OTP staff experiences. Results: We identified 4 overarching themes illustrating the successful integration of facilitated telemedicine for HCV care into OTPs. First, integration requires an understanding of the challenges, goals, and values of the OTP. As OTP staff learned about new, highly effective HCV therapies, they valued an HCV cure as a “win” for their patients and were excited about the potential to eliminate a highly prevalent infectious disease. Second, the integration of facilitated telemedicine into OTPs fosters social support and reinforces relationships between patients and OTP staff. OTP staff appreciated the ability to have “eyes on” patients during telemedicine encounters to assess body language, a necessary component of OUD management. Third, participants described high levels of interprofessional collaboration as a care team that included the blurring of lines between disciplines working toward a common goal of improving patient care. Study case managers were integrated into OTP workflows and established communication channels to improve patient outcomes. Fourth, administrators endorsed the sustained and future expansion of facilitated telemedicine to address comorbidities. Conclusions: OTP staff were highly enthusiastic about facilitated telemedicine for an underserved population. They described high levels of collaboration and integration comparable to relevant integrative frameworks. When situated within OTPs, facilitated telemedicine is a high-value application of telemedicine that provides support for underserved populations necessary for high-quality health care. These experiences support sustaining and scaling facilitated telemedicine in comparable settings and evaluating its ability to address other comorbidities. Trial Registration: ClinicalTrials.gov NCT02933970; https://clinicaltrials.gov/study/NCT02933970

The US government has established a national goal of hepatitis C virus (HCV) elimination by 2030. To date, most HCV elimination planning and activity have been at the state level. Fifteen states presently have publicly available HCV elimination plans. In 2019, Louisiana and Washington were the first states to initiate 5-year funded HCV elimination programs. These states differ on motivation for pursuing HCV elimination and ranking on several indicators. Simultaneously, however, they have emphasized several similar elimination components including HCV screening promotion through public awareness, screening expansion, surveillance enhancement (including electronic reporting and task force development), and harm reduction. The 13 other states with published elimination plans have proposed the majority of the elements identified by Louisiana and Washington, but several have notable gaps. Louisiana's and Washington's comprehensive plans, funding approaches, and programs provide a useful framework that can move states and the nation toward HCV elimination.

Background: People with opioid use disorder (OUD) have the highest rates of hepatitis C virus (HCV) infection. Despite the availability of curative HCV medication, people with OUD have limited health care access largely due to stigma. In a recent, pragmatic, randomized controlled trial (RCT), we compared a facilitated telemedicine intervention for HCV treatment integrated into opioid treatment programs (OTPs) with off-site referral. Facilitated telemedicine is bidirectional videoconferencing between a remote provider and a patient, supported by a case manager who facilitates the telemedicine encounter. The case manager schedules telemedicine visits, provides appointment reminders, and operates the digital equipment. Among 602 participants in the RCT, 90% (n=262) were cured through facilitated telemedicine and 39% (n=123) were cured through off-site referral. In this work, a multidisciplinary group of investigators, who directed the RCT, conducted a workshop, “Advancing Viral Hepatitis Screening and Treatment in Opioid Treatment Settings – Models & Resources,” at the American Association for Treatment of Opioid Dependence Conference in May 2024 to disseminate knowledge of facilitated telemedicine, including implementation considerations. We highlighted facilitated telemedicine as a patient-centered, sociotechnical, pragmatic health care delivery model for underserved populations. Objective: This study aimed to identify lessons learned to successfully overcome challenges of facilitated telemedicine implementation for HCV treatment integrated into OTPs. Methods: We partnered with the National Alliance of State and Territorial AIDS Directors in planning the workshop. The workshop consisted of 7 presentations on topics related to facilitated telemedicine implementation. The workshop was recorded and transcribed by Zoom (Zoom Communications). The transcripts served as data for the thematic analysis. The transcripts were interpreted to elucidate patterns of meanings and nuances derived from each presentation. In an iterative process, preliminary findings were compared and coalesced into themes. Verbatim quotes from the workshop were highlighted to support the themes. Results: We developed 3 themes. First, patient-centered care promotes HCV treatment for underserved populations through facilitated telemedicine. Case managers leveraged the destigmatizing environment of the OTP to build trust with patients, promoting an HCV cure through facilitated telemedicine. Second, sociotechnical approaches expand health care access for people with OUD. To be effective, facilitated telemedicine integrates 2 necessary components, a social aspect and a technical aspect. Third, facilitated telemedicine supports pragmatic research emphasizing people with OUD. Pragmatic research of facilitated telemedicine is needed to assess sustainability and scaling considerations beyond OTPs. Overall, we found that facilitated telemedicine overcame the digital divide, promoting access to digital technology, internet provision, and digital literacy. Conclusions: Facilitated telemedicine incorporates both a technical and a social component. The technical component largely addresses geographical challenges, while the social component addresses temporal (ie, care coordination) issues, promotes trust, and largely assuages patients’ concerns related to HCV treatment. The patient-centered, sociotechnical intervention can address the digital divide, thereby increasing health care access.

Although opioid use disorder (OUD) and hepatitis C virus (HCV) frequently co-occur, few studies have evaluated substance use and social determinants of health (SDOH) that predict HCV treatment initiation and sustained virologic response (SVR). We used administrative and clinical trial outcome data from HCV-infected methadone-treated participants (n=522) to evaluate changes in substance use and SDOH associated with HCV treatment initiation and SVR. We performed random forest analysis for investigating factors that predict HCV treatment initiation and SVR. Additionally, we applied the factor analysis for mixed data method for dimensionality reduction and used a clustering method to divide participants into subgroups to assess individual and regional-level differences. HCV treatment approach (i.e., through telemedicine or referral), methadone duration, age, and degree of substance use correctly identified HCV treatment initiation in 75% and SVR in 94% of participants, respectively. Grouping participants based upon SDOH (first principal dimension), substance use (second dimension), and medical comorbidities, mental health disorders and demographics (third dimension) identified individual and regional level differences. We identified changes in substance use and SDOH associated with HCV treatment initiation and SVR. Individual and regional-level subgroup differences could guide intervention implementation. HCV treatment initiation and SVR lead to improvements, not only in liver and infectious diseases outcomes, but in social and substance use factors.

Large language model (LLM)–based systems have tremendous potential to improve patient-centered health care, especially for medically underserved populations. However, realizing this potential requires careful consideration of the socio-technical contexts in which LLMs are used. The design of such systems should consider the vulnerabilities of any medically underserved group that the system intends to support, and provide trustworthy evidence for its use. This viewpoint reports the lessons learned from our experience and research with the CREATE (Culture, Respect, Education, Advancement, Trust, and Expertise) framework for engaging multiple stakeholders to guide the integration of LLM-based systems for improved health care delivery. We propose an extension of the traditional hierarchy of evidence model and identify key junction points in clinical workflows at which LLM-based systems can potentially be used to improve patient care. The key messages can be summarized as follows: (1) users of AI technologies, such as LLM-based tools, must be aware of the strengths, limitations, and impact of these technologies on health care delivery workflows and on the quality of generated evidence on which health care recommendations are based; (2) users must also be aware of the impact of data quality on AI outputs and on the evidence generated from the use of these systems; (3) the evidence pyramid provides a framework that facilitates the evaluation of the output generated by AI systems; (4) the CREATE framework facilitates the engagement of a variety of stakeholders. We propose concrete approaches for its validation and implementation; (5) any system designed to support people with opioid use disorder (OUD) needs to consider the overall lack of trust and stigmatizing experiences of this population with the health care system, and we discuss various aspects of the evaluation process necessary to build trust; (6) to discuss research directions that need to be addressed before LLM-based systems can be integrated usefully in patient health care.

BACKGROUND Telemedicine has the potential to remove geographic and temporal obstacles to health care access. Whether and how telemedicine can increase health care access for underserved populations remains an open question. To address this issue, we integrated facilitated telemedicine encounters for the management of hepatitis C virus (HCV), a highly prevalent condition among people with opioid use disorder (OUD), into opioid treatment programs (OTPs). In New York State, OTPs are methadone-dispensing centers that provide patient-centered, evidence-based treatment for OUD. We investigated the integration and impact of facilitated telemedicine into OTP workflows in these settings. OBJECTIVE This study aims to understand OTP staff experiences with integrating facilitated telemedicine for HCV treatment into OTPs, including best practices and lessons learned. METHODS We conducted semistructured interviews with 45 OTP staff members (13 clinical, 12 administrative, 6 physicians, and 14 support staff members) at least one year after the implementation of facilitated telemedicine for HCV management. We used hermeneutic phenomenological analysis to understand OTP staff experiences. RESULTS We identified 4 overarching themes illustrating the successful integration of facilitated telemedicine for HCV care into OTPs. First, integration requires an understanding of the challenges, goals, and values of the OTP. As OTP staff learned about new, highly effective HCV therapies, they valued an HCV cure as a “win” for their patients and were excited about the potential to eliminate a highly prevalent infectious disease. Second, the integration of facilitated telemedicine into OTPs fosters social support and reinforces relationships between patients and OTP staff. OTP staff appreciated the ability to have “eyes on” patients during telemedicine encounters to assess body language, a necessary component of OUD management. Third, participants described high levels of interprofessional collaboration as a care team that included the blurring of lines between disciplines working toward a common goal of improving patient care. Study case managers were integrated into OTP workflows and established communication channels to improve patient outcomes. Fourth, administrators endorsed the sustained and future expansion of facilitated telemedicine to address comorbidities. CONCLUSIONS OTP staff were highly enthusiastic about facilitated telemedicine for an underserved population. They described high levels of collaboration and integration comparable to relevant integrative frameworks. When situated within OTPs, facilitated telemedicine is a high-value application of telemedicine that provides support for underserved populations necessary for high-quality health care. These experiences support sustaining and scaling facilitated telemedicine in comparable settings and evaluating its ability to address other comorbidities. CLINICALTRIAL ClinicalTrials.gov NCT02933970; https://clinicaltrials.gov/study/NCT02933970