Acceptability of Telemedicine in a Geriatric Outpatient Practice During the COVID-19 Pandemic
Introduction
The use of telemedicine has grown exponentially over the past decade. The COVID-19 pandemic provided a “fast forward” for telemedicine use as the Centers for Medicare & Medicaid Services and many other organizations advocated for expanded health care delivery.1,2 During the initial pandemic surge, the percentage of primary care telemedicine visits increased from 1% prepandemic to 35.3% of visits throughout the United States.3 At the same time, overall primary care visit numbers decreased, indicating that individuals were foregoing care, most likely out of concerns about in-person safety and/or barriers to telemedicine use.3 Older adults have stood out as a uniquely vulnerable population throughout the pandemic—both in their vulnerability to infection-related morbidity/mortality and the strain of social isolation.4–7 The rapid shift in health care delivery toward a virtual landscape further complicates this picture.
Historically, there have been several prominent barriers limiting the reach and efficacy of telemedicine in older adults.3 One study found that telemedicine “unreadiness” increased significantly with increasing age—identifying “unreadiness” as having any one of the following: challenges with hearing, speech, cognition, vision, or lack of internet devices or use in the past month.8 The percent of “unready” older adults are reported to be 25% (among 65–74 years old), 44% (among 75–84 years old), and up to 72% (among those >85 old).8 Computer illiteracy, financial cost, physical/cognitive impairments, and a lack of desire to engage with technology are among the most frequently identified limiting factors in telemedicine use among older adults.9–11
A 2018 national prevalence assessment estimated that approximately one-third of older adults in the United States remain inexperienced with the technology essential for telemedicine, despite having access to social supports and experienced family members.8 Additional risk factors for low telemedicine uptake include non-white race or ethnicity, rural location, low socioeconomic status, low educational attainment, and poor self-reported health.12–14
According to the National Poll on Healthy Aging, there was a significant uptake in the percentage of telemedicine offered to older patients during the pandemic.15 Fourteen percent of older patients were offered telemedicine in May 2019 versus 62% offered in June 2020.15 Despite this rapid pivot to telemedicine during COVID-19 and the potential telemedicine challenges faced by older adults, few studies have focused exclusively on outpatient telemedicine use in older patients16,17 and no studies have explored older adults’ experiences and satisfaction with telemedicine in Philadelphia. The purpose of this study was to survey utilization trends and satisfaction levels with telemedicine among geriatric patients at an urban practice during the pandemic. These findings can inform practice efforts to support the older adults utilizing telemedicine as it becomes an increasingly standard tool in primary care.
Methods
SETTING
The Center for Healthy Aging (CHA) at Jefferson Health and Thomas Jefferson University (TJU) is located in downtown Philadelphia, Pennsylvania. It is home to 1.5 million residents, with over 200,000 people 65 years of age and older. Philadelphia is a diverse city; its residents are 42.2% black/African American, 36.9% non-Hispanic white, 12.3% Latino/Hispanic, and 6.3% Asian.18 Within the boundaries of the City of Philadelphia, 17% of adults did not graduate high school and only 27.4% carry college degrees—rates sitting well below the national average of 30%.19 In addition, the percentage of persons living in poverty in Philadelphia is 24.3%, significantly higher than both national and state percentages at 11.4% and 12.0%, respectively.19
The CHA is an outpatient primary care practice for patients 55 years and older. At the start of the COVID-19 pandemic, CHA providers and staff assisted patients in navigating a rapidly evolving landscape within health care by providing in-person appointments in the office and expanding telemedicine access. Over the course of the pandemic, the practice experienced an exponential increase in the use of the technology; telemedicine visits accounted for <5% of all visits prepandemic and increased to a maximum of 81% of all encounters during the height of the pandemic in Philadelphia during October 2021.
Beginning in March 2020, all provider panels were built to accommodate individual needs/preferences of patients to schedule in-person or telemedicine visits. The ability to transition “on-demand” from one visit type to the other empowered patients to optimize their experience with the health care system and maximized patient/provider safety in the face of rising rates of community infection. All staff were trained to provide patient/family assistance in setting up MyChart accounts (electronic patient portal) and navigating the telemedicine technology. Providers were given online training from the institution in how to complete telemedicine visits. These visits were completed on smartphones or iPads. Through the FCC Cares Act and funding through the FCC Telehealth Grant Program, TJU Hospital purchased iPads to distribute to vulnerable, low-income patients with chronic illness during the pandemic to enhance telemedicine access. The CHA obtained 65 iPads through this grant, along with blood pressure cuffs and scales, and distributed these to qualifying low-income older adults with chronic illness.
SAMPLING AND RECRUITMENT
The CHA has a patient panel of ∼1,400 patients over the age of 55. Approximately 78% of these patients were registered in the MyChart patient portal at the time of the survey distribution. Through the portal, patients were invited to participate in an institutionally IRB-approved, anonymous Qualtrics survey on March 16, 2021. The surveyed population self-identified as Black/African American (50%) white (40%), Latino (3%), Asian (3%), and “other” (4%). This breakdown closely aligns with Philadelphia’s racial/ethnic demographics. Additionally, this population comprised 71% Medicare (including Medicare Advantage, dual-eligible), 23% non-Medicare/non-Medicaid, and 6% Medicaid.
DATA COLLECTION
Participants were asked four Yes/No questions, seven Likert scale questions and six open-ended questions. Participants were asked if they had completed a telemedicine visit at CHA—if they responded “yes,” they were asked to rate their satisfaction with telemedicine and describe the best and most frustrating aspects of telemedicine through open-ended responses. Respondents were permitted to provide multiple responses to each open-ended inquiry. They were also asked to rate their confidence completing a telemedicine visit without assistance from a CHA staff member, caregiver, family member, or friend. If participants had not completed a telemedicine visit, they were asked to select from a list of barriers. All participants were also asked if they were concerned about the costs of telemedicine visits, plans to use telemedicine after the pandemic, concerns about in-office visits, how well supported they felt by CHA during the pandemic, and if they had received an outreach call from CHA staff.
Frequencies were calculated for close-ended questions. Through thematic analysis, two authors coded patient responses to the open-ended inquiries and identified larger themes centering around benefits and limitations of telemedicine. Table 1 provides representative patient responses that were used to identify broad themes.
| DOMAIN | THEME | SAMPLE RESPONSE | PATIENT RESPONSE |
|---|---|---|---|
| Description of the best aspects of telemedicine | Safety | “Being safe in your own home.” | 7.95% (7/88) |
| Equivalency to in-person visit | “Similar to a regular visit without the embarrassment of standing on the scale.” | 50% (44/88) | |
| Convenience | “Not leaving the house in inclement weather.” | 42.05% (37/88) | |
| Other | “The fact that it was available.” | 3.41% (3/88) | |
| None | “None.” | 1.14% (1/88) | |
| Description of frustrating aspects of telemedicine | Technical difficulties | “Unable to see visual contact and there were problems with the audio system.” | 31.4% (27/86) |
| Equivalency to in-person visit | “Lack of physical presence to see skin condition and swelling.” | 26.74% (23/86) | |
| Other | “Uncertainty about the technology” | 6.98% (6/86) | |
| No problems cited | “I had no problems with my telemedicine visit.” | 34.88% (30/86) |
Results
Of the 1,092 patients who received the survey, a total of 244 (22.3%) responded. Out of the respondents, 107 patients (51.44%) reported utilizing telemedicine for their visits. Of those patients who used telemedicine, 79.17% rated their experience overall as excellent or good (Table 2). This survey explored reasons for the positive experience reported by patients. Patients reported the telemedicine visit was “similar to a regular visit without the embarrassment of stepping on a scale.” Another patient described the telemedicine visit as “wonderful to be able to talk with the doctor without having to go out.” Further details are included in Table 1.
| TOPIC | RATING | PATIENT RESPONSE |
|---|---|---|
| Overall experience with telemedicine | Poor | 5.82% (6/103) |
| Somewhat fair | 1.94% (2/103) | |
| Fair | 12.62% (13/103) | |
| Good | 44.66% (46/103) | |
| Excellent | 34.95% (36/103) | |
| Concern associated with costs of telemedicine | Not at all concerned | 62.14% (64/103) |
| Mostly unconcerned | 7.77% (8/103) | |
| Neutral | 18.45% (19/103) | |
| Somewhat concerned | 9.71% (10/103) | |
| Very concerned | 1.94% (2/103) |
A small subset (8.33%) of patients who used telemedicine found the visit to be somewhat fair or poor. Patient comments describing their negative experience included “I had to wait to be able to connect.” “Obviously that the doctor cannot see, touch in order to assess the medical condition. Not getting blood pressure and weight on the spot.”
This survey also explored the confidence levels of older patients in using telemedicine. Around 46.32% of patients were very confident in using telemedicine without staff support. Similarly, 54.64% were confident in doing telemedicine without family member support. Lack of internet or not having a smartphone was only reported by 16.66% of patients. Cost was also not a major concern for 72.91% of patients. Interestingly, only 48.18% of patients planned to use telemedicine again despite the positive reports.
The following tables/figures present data trends identified through analysis of the collected data from March through May 2021.
Discussion
In this survey of patients at an urban geriatrics practice, 79.17% of respondents rated their experience with telemedicine as good or excellent. A significant percentage of patients cited safety (by limiting risk of exposure to COVID-19) and convenience as major benefits of telemedicine. Others commented on the ease of accessibility by foregoing travel expenses and excessive wait times. While studies predating the pandemic noted that discussing sensitive matters is often difficult over the telemedicine platform, often requiring reorientation of the patient/provider interaction,20,21 patients in this study did not report that difficulty and felt well supported. Many commented easily being able to perceive provider concern and empathy, effectively building patient/provider rapport. In addition, patients appreciated the more focused line of questioning that seemed more evident in telemedicine visits as well as a decrease in distractors usually found in office visits.
Contrary to widespread belief, our findings demonstrate a willingness of older adults to embrace the utility and usability of information technology in health care delivery. This finding supports previous studies over the past decade citing older adults wishing to keep abreast with technological advancements.22,23
User confidence was one of the surveyed items of this study. Overall, patient confidence correlated with prior technological experience. Patients who were able to successfully navigate the online technology reported higher confidence levels than those who were unable to after briefing of telemedicine protocols. Of the surveyed patients, 21% did not feel confident using telemedicine without family member, caregiver, or friend help, and about 14% did not feel confident without staff member help from our results (Fig. 1). This finding highlights the importance of support from both family/caregivers and office staff in facilitating patient success with telemedicine and underscores the need to understand what specific supports are needed among this population to optimize efficiency and efficacy.
Fig. 1. Patient reported confidence in completing telemedicine visits without the support of caregiver/family or office staff.
Although most patients admitted to initially feeling uneasy with using telemedicine for their visits, a few reported positive experiences on the utility of medical assistants and ancillary staff with troubleshooting technological issues. This provides a unique opportunity for fostering trust between not only the whole health care team and the patient, but also within interprofessional domains. In telemedicine introduction, a patient-centered approach proves an important condition for its successful implementation.24
As with other studies,20 respondents identified technical difficulties as their primary contention against telemedicine, noting frustrations in various components of their visit with the audio system, internet connection, or lack of nonverbal cues. A subset of patients also expressed concerns about troubleshooting either internet or equipment issues arising within a visit. Previous studies of telemedicine acceptance have identified computer anxiety as a salient predictor of negative attitude and diminished intention to technology use.25,26 Despite trained staff and providers aiding patients and family members, some commented on receiving unclear instructions, which was a factor in failed video appointments. The implementation of a thorough yet easily understandable protocol as well as real-time assistance from staff could reduce these concerns and prevent future unintended trouble with connectivity.
A small proportion of patients also reported that they preferred in-person visits, expressing desire for a physical examination as part of a full evaluation as well as the role of physical presence in developing the patient/provider relationship. While this viewpoint was not surprising,27 only a small fraction of patients in our study shared this sentiment, suggesting a fundamental shift in attitude and perspective because of the COVID-19 pandemic.
This study identifies two key strategies that supported the positive patient experience with telemedicine. (1) Staff called to check with patients to make sure they had the necessary tools and instructions to conduct a virtual appointment. Efficient and frequent communication strategies (i.e., tiger texting) allowed clinical teams to quickly identify and troubleshoot technical/medical/psychosocial concerns. (2) Streamlined coordination between different clinical team members. Although many team members worked remotely, patient and family member needs and concerns were continually addressed. Behavior health consultants, for example, provided remote access and family counseling, effectively combating the loneliness and anxiety expressed by many older patients during the pandemic.5–7
Although we did not explore the concept of support in detail, it is reassuring that 66.35% of patients surveyed felt “supported” or “well supported” by the practice during the pandemic. Potential factors included direct phone outreach to our patients by the medical assistants and proactive scheduling of telemedicine visits. While previous studies have also echoed the benefit of team-based care in telemedicine,28 future work would be needed to further delineate these potential factors.
Strengths of this study include its user-friendly administration and ease of accessibility. Survey components are written with consideration of local education and health literacy levels, especially since age has been negatively associated with health literacy.29 Using plain and simple language ensures effortless and straightforward survey completion. The primary limitation in this study is its online administration. Evaluating barriers to telemedicine and technology through an electronically delivered survey can lead to bias and may preclude those patients who are most challenged by technology (and telemedicine) from participating. To overcome this, a future direction for this study could involve incorporating in-person surveys. Our study sample size is also small, which could limit the power of our findings and potentially limit the generalizability of our findings. Specific demographic information is also not collected for patients in the study sample, which may differ from the overall demographic population of patients served in Jefferson’s CHA.
In addition, disparities in digital literacy and access to technology are evident within patients in our practice, potentially impacting quality and diagnostic accuracy despite efforts on patient outreach and education.30 Positioned at one time as a nascent health care delivery modality, the pandemic has pushed the practice of telemedicine into mainstream and/or customary practice in many communities. However, telemedicine is still considered ancillary to, not a replacement of, in-person evaluation. This study highlights the need for additional research to better understand the optimal use and limitations of telemedicine.
Conclusions
In this survey of patients at an urban geriatrics practice, most older adults were confident in using telemedicine as an alternative to in-person visits during the COVID-19 pandemic and plan to use it again. While results prove telemedicine can work effectively, there is a need for additional evaluation to further understand the acceptability, usefulness, limitations, and efficacy of telemedicine utilization among older adults.
Since age-related factors, education levels, race, and socioeconomic status affect the interaction of older adults with telemedicine, it would be informative to stratify based on age groups, additional health conditions, and education within the geriatric population. Expanding this study in other similar and disparate geriatric settings would also have additional value. Long-term longitudinal studies following older adults with chronic medical conditions could provide further comprehensive understanding of telemedicine and establish its viability. Future work in this area will include a better delineation of the factors that influence perceived support from a geriatrics practice, provider and staff perceptions of telemedicine, and sociodemographic factors, including level of education, race, and socioeconomic factors influencing telemedicine care delivery.
Acknowledgments
The authors thank Jackie Raab, MSN, RN, Jennifer Langley, EdD, ATC, Wydera Stubbs, CCMA, and Stephanie Pilotti, NRCMA for the support and input.
Authors’ Contributions
D.N.F.R.: Validation, Investigation, Data curation, Writing—Original draft, Review and editing, and Visualization. A.C.: Conceptualization, Methodology, Software, Validation, Investigation, Resources, Writing—Review and editing, and Supervision. L.R.H.: Conceptualization, Methodology, Software, Validation, Investigation, Resources, Writing—Review and editing, and Supervision. B.S.: Conceptualization, Methodology, Software, Validation, Investigation, Resources, Writing—Review and editing, and Supervision. S.M.P.: Conceptualization, Methodology, Software, Validation, Investigation, Resources, Writing—Review and editing, Supervision, Project administration, and Funding acquisition.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
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