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Telemedicine in Primary Care During the COVID-19 Pandemic: Provider and Patient Satisfaction Examined

Editor


Introduction

Telemedicine has been defined as “the use of electronic information and communications technologies to provide and support health care when distance separates the participants.” It was initially implemented as a way to expand health care access to patients in remote locations.1 Over time and as technology became ubiquitous, electronic medical record (EMR) platforms advanced and internet access became widespread. Expanses in telemedicine applications were able to follow.2

In December of 2019 an outbreak of pneumonia caused by the severe acute respiratory syndrome coronavirus 2 was identified in Wuhan, China.3 This contagious virus (COVID-19) rapidly spread, and by the end of January 2020, it was considered an international public health emergency. By March 2020 it had been declared a pandemic by the World Health Organization.4 Effective treatments, as well as vaccines, for COVID-19 were rapidly investigated and developed. In the meantime, however, public health measures, including universal masking, social distancing, and avoiding large crowds, became of paramount importance to control the spread of this potentially fatal disease.5

During this pandemic, health care professionals turned to telemedicine to help slow the spread of COVID-19 while still providing patients access to the care they needed.6–8 Rapid implementation of telemedicine services was undertaken by a large number of health care entities. This was greatly facilitated by the Centers for Medicare and Medicaid Services passing an emergent and temporary broadening of coverage for telemedicine services.9 Provider and patient satisfaction with these visit types has initially been reported as positive, but long-term concerns remain regarding the postpandemic role for telemedicine.10,11

The purpose of this study was to identify factors associated with both provider and patient satisfaction with telemedicine visits in a primary care setting during the COVID-19 pandemic.

Materials and Methods

This study was approved by the Mount Auburn Hospital Institutional Review Board. Telemedicine visits included both video and phone (audio only) visits. Primary care providers in a community hospital within a quaternary care network were emailed and asked to participate in a survey on their experiences with telemedicine visits throughout the COVID-19 pandemic. Those that participated were offered the option to have the patients they saw in telemedicine visits receive a similar survey asking about their experiences. For each provider who wished to have their patients participate, schedules were reviewed and virtual visits identified. Patients’ e-mail addresses were obtained from the EMR, and surveys were distributed using Qualtrics© survey software. Patients who had virtual visits with the responding providers received a survey invitation through e-mail in November of 2020 for any telemedicine visit from March 2020 until then. Two reminder e-mails were sent if they did not complete the survey at 1 and 3 weeks after initial distribution.

Data from provider and patient survey responses were collected using Qualtrics© and exported in to STATA 15.1 for statistical analysis. If a patient had participated with more than one survey response, only their first response was analyzed. For select analysis: age, satisfaction, ease or difficulty connecting, and travel time were all converted into binary outcomes. Age was categorized as “50 or under” and “51 or over.” Binary outcomes for satisfaction were ‘satisfied’ as “very satisfied” and “somewhat satisfied” and ‘not satisfied” as “neither unsatisfied or satisfied,” “somewhat unsatisfied,” and “very unsatisfied.” Ease of connection was classified as ‘easy’ for those that stated it was “easy to connect” and all other options as “not easy.” Travel time was divided into less than or greater than 30-min categories. Descriptive statistics and proportions were used to demonstrate data. Pearson’s Chi Squared was used to evaluate categorical and binary variables. Logistic, ordered logistic regression, and multivariate logistic regression were used to further evaluate variables. Age and gender were forced into the multivariate model, and other variables were added if their p-value was <0.2.

Results

Primary Care Provider Responses

Seventy-three (N = 73) primary care providers received a survey invitation, and 24 participated with a 96% survey completion rate (22 physicians and 1 nurse practitioner) (Appendix Tables A1 and A2). Of those who participated 14 (58.3%) agreed to have their patients receive a similar survey about their telemedicine experience. The majority of providers who responded were female, white, and non-Hispanic or Non-Latino (Appendix Table A1).

Overall, 95.7% of providers reported that they would like to see virtual visits being offered in the future, while only 17.4% offered virtual visits before the COVID-19 Pandemic. Only one provider felt that virtual visits took more time than in-person visits (Table 1). Despite 87% of providers being satisfied with virtual visits, only 17.4% reported that they could provide effective care using only virtual visits (Appendix Table A1).

Table 1. Provider Responses to Length of Time Needed for Conducting In-Person Versus Telemedicine Visits
In-person visits take longer 69.6%
In-person and telemedicine visits take the same amount of time 26.1%
Telemedicine visits take longer 4.4%

Patient Responses

There were 1,873 patient responses representing 1,791 unique patients (82 duplicates and triplicates were removed leaving only the first response for analysis). A majority, 1,766 (98.6%), who clicked on the e-mail survey link consented to participate, and 1,692 (94.5%) completed all of the survey questions. Patient demographics are shown in Table 2 and demonstrate that most participants were female (70.8%), white (89.7%), non-Hispanic or non-Latino (96.6%), and Massachusetts residents (96.9%).

Table 2. Patient Demographics for Survey Respondents
CHARACTERISTIC N (%)
Consented to participate
 Yes 1,766 (98.6)
 No 25 (1.4)
Completed survey
 Yes 1,692 (94.5)
 No 99 (5.5)
Age category
 18–30 71 (4.2)
 31–40 175 (10.4)
 41–50 229 (13.6)
 51–60 343 (20.4)
 61–70 436 (26.0)
 71 and over 424 (25.3)
Gender
 Female 1,187 (70.8)
 Male 485 (28.9)
 Other 5 (0.3)
Race
 White 1,473 (89.7)
 Asian 100 (6.1)
 Two or more races 39 (2.4)
 Black or African American 28 (1.7)
 Naive Hawaiian or other Pacific Islander 1 (0.1)
 American Indian or Alaska Native 1 (0.1)
Ethnicity
 Hispanic or Latino 54 (3.4)
 Non-Hispanic or non-Latino 1,538 (96.6)
Patient location during virtual visit
 Massachusetts 1,503 (93.8)
 New Hampshire 32 (2.0)
 Maine 16 (1.0)
 Vermont 11 (0.7)
 Connecticut 7 (0.4)
 Rhode Island 5 (0.3)
 Other state 29 (1.8)
Massachusetts resident
 Yes 1,631 (96.9)
 No 52 (3.1)

Patients were asked if they felt comfortable speaking to their PCP about personal issues in telemedicine visits. Of the participants, 96.5% reported that they did feel comfortable. Most participants (78.8%) reported that connecting virtually was “very easy,” and 94.4% of participants reported that they had everything they needed to participate in these visits. Responses on comfort, connection difficulty, and need to acquire materials ranged depending upon the platform used. The Zoom© platform was the most widely used in this study as it was integrated into the medical record for patients and providers (Appendix Table A3). Participants reported greater comfort and ease in connecting with Zoom© versus other methods.

The overwhelming majority of patients reported that they were “very satisfied” with their telemedicine visit (75.8%) with less than 1% being “very dissatisfied.” Almost all patients (97.4%) saved time by utilizing virtual visits and not traveling to in-person appointments (Fig. 1).

Fig. 1.

Fig. 1. Patient satisfaction with telemedicine visits and the amount of travel time saved with these visit types.

Patients were asked about their preference for visit type (telemedicine or in-person) when it is safe to fully reopen after the pandemic. Of the participants, 70.4% reported that they prefer to use a combination of both telemedicine and in-person visits, with only 26.7% reporting that they prefer to use only in-person visits.

In univariate logistic regression, satisfaction was correlated with ease of connection and amount of travel time saved (Appendix Table A4). It was inversely correlated with telephone use versus Zoom or need to acquire “some or everything for a visit.” Participants that rated the ease of connection as “easy” had an odds ratio (OR) of 3.5 (95% confidence interval [CI] 2.4–5.2) for satisfaction compared with those that reported the connection was “not easy.” Likewise, participants that saved greater than 30 min of travel time due to virtual visits had an OR of 1.8 (95% CI 1.2–2.6) for satisfaction compared to those that saved less than 30 min of travel time. Participants that had a telemedicine visit through video platforms (“other video platform” or Zoom©) were more likely to be satisfied and had an OR of satisfaction of 2.2 (95% CI 1.2–4.0) and 2.7 (95% CI 1.8–4.0), respectively, compared to those that had a telephone visit.

Likewise, participants who had to acquire some or everything for the visit were also less likely to be satisfied with their visit, an OR of 0.4 (95% CI 0.2–0.8) and 0.3 (95% CI 0.1–0.9), respectively. See Appendix Table A3 for other variables.

In multivariate logistic regression, travel time saved >30 min (OR 1.8), having an easy connection (OR = 3.2), and use of a video platform (other video platform OR = 2.4, Zoom platform 2.8) continued to be significantly associated with satisfaction. Identifying as female also became significantly associated with satisfaction (OR 1.8) in the multivariate model (Table 3).

Table 3. Multivariate Logistic Regression for Patient Factors
VARIABLE OR P 95% CI
Age (reference = <50)
 Over 50 1.3 0.20 0.9–2.1
Gender (reference = male)
 Female 1.8 0.01* 1.1–2.7
 Other 0.2 0.20 0–2.2
Ease of connection (reference = not easy)
 Easy connection 3.2 <0.001* 2.1–4.9
Need to acquire material (reference = I had everything I needed for the visit)
 I had to acquire some things for the visit 0.7 0.37 0.4–1.5
 I had to acquire everything for the visit 0.5 0.32 0.1–2.0
Platform used (reference = telephone)
 Other video platform 2.4 0.01* 1.2–4.5
 Zoom 2.8 <0.001* 1.8–4.4
Travel time (reference = <30 min)
 >30 min 1.8 0.005* 1.2–2.7

Discussion

By understanding the advantages of telemedicine, factors that lead to successful use, and the desire to have the option after the pandemic, health care providers and institutions can optimize workflows, EMRs, and office space.

Discussing Provider Responses

From this study we are able to determine some trends for providers: the majority of providers stated that telemedicine visits take less time than in-person visits, and all but one provider stated that they have the desire to offer telemedicine visits in the future. Due to the continued demands for high patient volumes and patient satisfaction in primary care settings, telemedicine may prove to be a useful way to meaningfully connect with patients while maximizing scheduled time. This finding is opposed to the view some hold on EMRs in general that they cause an increase in time spent per patient without valuable face-to-face time. Studies have shown that EMR interaction time takes up 45% of a primary care provider’s workday and an additional 1.4 h/day on average outside of clinic time.12

Most providers felt that they could not provide effective care with only telemedicine visits. This was not a surprising finding considering the need for in-person evaluation and treatment for certain chief complaints and procedural visits. Interestingly, more than half of providers who responded did not know if their professional liability coverage extended to telemedicine visits. This likely is a result of the rapid implementation of the technology and limited alternatives for outpatient care. It turns out that liability coverage does extend to the telemedicine visits that were utilized. This highlights the importance of institutional education programs on this matter.

Discussing Patient Responses

This study revealed four factors associated with significantly higher levels of patient satisfaction with telemedicine visits. These included (1) travel time saved >30 min (OR of 1.8, 95% CI 1.2–2.7), (2) easy to connect (OR 3.2, 95% CI 2.1–5.0), (3) using a video platform over telephone platform (OR 2.3, 95% CI 1.2–4.4 for “other video platform” and OR 1.8, 95% CI 1.8–4.4 for Zoom©), and (4) female gender (OR 1.8, 95% CI 1.1–2.7). The associations with travel time saved, ease of connection, and use of a video platform over telephone platform intuitively make sense. Future studies could elaborate on if gender preferences for in-person or telemedicine visits prevail in other settings as well.

Things that were importantly not found to be associated with telemedicine visit satisfaction included age, race, and ethnicity. There are data that have shown older adults to be less likely to adapt to newer technology.13 We however found that there was no difference with respect to telemedicine satisfaction in either binary age (> or <50 years old) or categorical age ranges. Knowing this makes the adaptation of telemedicine more palatable for providers who see adult patients. In the setting of a global pandemic where older patients are at higher risk of severe disease and death, this finding may be confounded by the desire of older patients to avoid leaving their homes and be more willing to use telemedicine to prevent exposure to the virus. Postpandemic studies will be needed to determine the relationship at that point.

Other notable findings for patients included very high levels of comfort discussing personal issues with telemedicine visits, very high levels of satisfaction overall with telemedicine, and large amounts of time savings by eliminating travel time. Only 26.7% of patients stated that they would like to have only in-person visits when it is safe to reopen. This speaks favorably toward the ongoing offering of this visit type. Historically telemedicine adaptation has been hindered by a multitude of factors and some but not nearly all have been addressed during the COVID-19 pandemic.14–16

Providers in this study were all based in the state of Massachusetts, but 6.2% of patient respondents were located outside of the state during their telemedicine visit. This finding has implications for multistate licensure requirements for physicians and reimbursement within acceptable operating margins when Centers for Medicare & Medicaid Services regulations change postpandemic.17

The strengths of this study include its large sample size for patient responses and high survey completion rate. Limitations include: recall bias, response bias, and sampling bias. Some surveys may have been received by patients several months after their visit and may reflect inaccurate recall of their experience. It is also possible that providers who were more comfortable with telemedicine agreed to have their patients included which could have affected results. The location of this study included a narrow demographic range of patient respondents, which led to a lack of heterogeneity in this study. It potentially makes the results nongeneralizable to other parts of the country.

Conclusions

Patients and providers both are satisfied with telemedicine visits in primary care. They both wish to see these visit types continued in the future.

Providers feel that telemedicine visits usually take the same amount or less time than in-person visits.

Patients who: (1) saved travel time, (2) found it easy to connect, (3) used video platforms over telephone only, and (4) who were female were significantly more likely to be satisfied with their primary care telemedicine visits.

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

No funding was received for this project.

References

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Appendices

Appendix A1. Patient Survey

For this survey “virtual visits” are visits with health care personnel that take place over the phone or video software. They do not count visits when you go to the doctor’s office and see each other in-person.

If you were physically located in another state during any VIRTUAL visit with us please select that state below

Is Massachusetts your permanent state of residence?

Overall how satisfied were you with your virtual visit with your primary care provider (PCP)?

How much time did you save by not traveling to and from the doctor’s office for your virtual visit?

  • No time

  • 1–15 min

  • 15–30 min

  • 30–60 min

  • 1–2 h

  • More than 2 h

Do you prefer virtual visits or in-person visits with your PCP?

When Massachusetts and doctors offices are safe to fully reopen I prefer to use:

  • Virtual visits

  • In-person visits

  • A combination of both

Did you possess all of the technology necessary for your virtual visit or did you have to acquire it for the visit? (e.g., phone, internet, webcam, blood pressure cuff, scale, etc.)

  • I had everything I needed for the visit

  • I had to acquire some things for the visit

  • I had to acquire everything for the visit

Did you feel comfortable speaking to your PCP about personal issues in virtual visits?

How difficult was it to connect with us online?

How was your visit conducted?

  • Telephone

  • Zoom video

  • Other video

What is your age?

  • 18–30

  • 31–40

  • 41–50

  • 51–60

  • 61–70

  • 71–80

  • 81–90

  • 91 +

What is your gender?

What is your race?

  • White

  • Black or African American

  • Asian

  • American Indian or Alaska Native

  • Naive Hawaiian or other Pacific Islander

  • Two or more races

What is your ethnicity?

Appendix Table A1. Demographics of Primary Care Providers Who Took the Survey
Age, n (%)
 18–30 1 (4.3)
 31–40 4 (17.4)
 41–50 5 (21.7)
 51–60 7 (30.4)
 61–70 3 (13.0)
 71–80 3 (13.0)
Years in Practice, n (%)
 0–4 3 (13.0)
 11–15 4 (17.4)
 21–30 8 (34.8)
 31–40 2 (8.7)
 41+ 3 (13.0)
 5–10 3 (13.0)
Gender, n (%)
 Female 18 (78.3)
 Male 5 (21.7)
 Other 0 (0)
Race, n (%)
 White 21 (91.3)
 Black or African American 0 (0)
 Asian 2 (8.7)
 American Indian or Alaska Native 0 (0)
 Native Hawaiian or other Pacific Islander 0 (0)
Ethnicity, n (%)
 Non-Hispanic or non-Latino 22 (95.7)
 Hispanic or Latino 1 (4.3)

Appendix Table A2. Primary Care Provider Responses to Questions About Telemedicine Satisfaction
QUESTION N (%)
To cover the same amount in a visit
 I usually spend the same amount of time either way 6 (26.1)
 In-person visits tend to take longer 16 (69.6)
 Virtual visits tend to take longer 1 (4.3)
Would you like to see virtual visits continued to be offered in the future?
 No 1 (4.3)
 Yes 22 (95.7)
I feel that virtual visits are appropriate for
 All of the visit types I see 0 (0)
 Most of the visit types I see 5 (21.7)
 Half of the visit types I see 10 (43.5)
 Less than half of the visit types I see 8 (34.8)
 None of the visit types I see 0 (0)
Do you feel that you could provide effective care using only virtual visits?
 No 19 (82.6)
 Yes 4 (17.4)
Satisfaction with the interpersonal patient connection in telephone only visits
 Very satisfied 1 (4.3)
 Somewhat satisfied 12 (52.2)
 Neither satisfied nor unsatisfied 6 (26.1)
 Somewhat unsatisfied 1 (4.3)
 Unsatisfied 3 (13.0)
Satisfaction with the interpersonal patient connection in video visits
 Very satisfied 8 (34.8)
 Somewhat satisfied 12 (52.2)
 Neither satisfied nor unsatisfied 0 (0)
 Somewhat unsatisfied 2 (8.7)
 Unsatisfied 1 (4.3)
Did you provide virtual visits before the COVID-19 pandemic?
 No 19 (82.6)
 Yes 4 (17.4)
Do you feel that appropriate current procedural terminology (CPT) codes exist for documentation of your visits?
 No 7 (31.8)
 Yes 15 (68.2)
Does your professional liability insurance cover virtual visits?
 I do not know 13 (56.5)
 Yes 10 (43.5)
 No 0 (0)
I feel that patients were able to utilize virtual visits successfully
 All of the time 0 (0)
 Most of the time 15 (65.2)
 Half of the time 5 (21.7)
 Less than half of the time 3 (13.0)
 Not at all 0 (0)
What is your preferred platform for virtual visits?
 Telephone 2 (9.1)
 Zoom video 14 (63.6)
 Other video 6 (27.3)

Appendix Table A3. Patient Responses to Questions Based Upon the Telemedicine Platform Used
  TELEMEDICINE PLATFORM  
OTHER VIDEO TELEPHONE ZOOM VIDEO P
N = 239 N = 478 N = 948  
Comfortable discussing personal issues
 Yes 230 (96.6) 444 (93.7) 923 (97.9) <0.01
 No 8 (3.4) 30 (6.3) 20 (2.1)
Level of difficulty connecting
 Very easy 184 (77.0) 347 (75.4) 771 (81.4) <0.01
 Took some time and effort 47 (19.7) 65 (14.1) 161 (17.0)
 Difficult 4 (1.7) 20 (4.3) 13 (1.4)
 Could not connect 4 (1.7) 28 (6.1) 2 (0.2)
Did you possess all of the technology necessary?
 I had everything I needed for the visit 227 (95.8) 428 (91.1) 904 (95.6) 0.01
 I had to acquire everything for the visit 1 (0.4) 7 (1.5) 6 (0.6)
 I had to acquire some things for the visit 9 (3.8) 35 (7.4) 36 (3.8)

Appendix Table A4. Univariate Logistic Regression for Patient Satisfaction with Telemedicine Visits
VARIABLE OR p 95% CI
Age (reference = <50)
 Over 50 1.0 0.94 0.7–1.5
Gender (reference = male)
 Female 1.4 0.14 0.9–2.0
 Other 0.4 0.38 0.04–3.4
Massachusetts resident (reference = no)
 Yes 1.7 0.22 0.7–4.1
Racea (reference = White)
 African American/Black 1.0 0.96 0.2–4.1
 Asian 1.9 0.23 0.7–5.1
 Two or more races 1.4 0.63 0.3–6.0
Ethnicity (reference = not Hispanic or Latino)
 Hispanic or Latino 1.2 0.73 0.4–4.0
Ease of connection (reference = not easy)
 Easy connection 3.5 <0.001* 2.4–5.2
Need to acquire material (reference = I had everything I needed for the visit)
 I had to acquire some things for the visit 0.4 0.01* 0.2–0.8
 I had to acquire everything for the visit 0.2 0.04* 0.1–0.9
Platform used (reference = telephone)
 Other video platform 2.2 0.01* 1.2–4.0
 Zoom 2.7 <0.001* 1.8–4.0
Travel time (reference = <30 min)
 >30 min 1.8 0.003* 1.2–2.6





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