Assessing Telehealth Through the Lens of the Provider: Considerations for the Post-COVID-19 Era

With value-based care flourishing, responses from the survey indicate that all providers believe telehealth has a key role in patient centricity. Creating standardized practices to promote patient retention, satisfaction, and superior outcomes is a goal in value-based care models.^2,15–17 This survey provides some evidence that many providers are ready and willing to redefine their strategies in patient care.

TOP CONCERNS

Technology limitations were noted to be one of the main barriers in achieving universal telehealth usage. It is of note that this was also a concern before the COVID-19 pandemic.^1,4 For telehealth to serve as a viable alternative, provider offices and hospitals need to invest in appropriate technology infrastructure, including broadband internet, smart device registration, digital peripherals, appropriate data security, and device sanitization protocols.¹⁸ Our respondents noted that the current guidelines were substandard.

An important consideration with digital care is patient privacy. Respondents noted that there is a need for a real plan for how to protect patient privacy. This concern was commented on by respondents as having to perform visits from a shared workroom or patients participating in visits in a public setting. Additional privacy concerns included data monitoring and transmission by third-party telehealth vendors. This can become a possible security threat when integrating new technology.¹⁹

To mitigate this, it is important for health care organizations to use only platforms that comply with data privacy policies already in place, such as the Health Insurance Portability and Accountability Act (HIPAA), and offer additional network security protocols and safety features.

It is known that technology transition in health care can be difficult and cumbersome. However, current literature shows that once appropriate technology is implemented, numerous benefits follow, including decreased patient waiting times, decreased no-show rates, and improved quality outcomes.^3,20

Yet, even if the technology hurdle can be overcome, providers may worry about the quality of care following the switch to digital interactions. For instance, a pulse survey in 2020 found that of the providers who decided not to utilize virtual services, almost half cited the possibility of reduced quality of care as their main concern.²¹ This sentiment was reproduced in our survey, where clinical quality was cited as a top concern among all pediatric providers.

In the same respect, the most reported criticism regarding telehealth use was a concern over diagnostic limitations and subsequent quality limitations. However, similar to other concerns, the ability to ensure clinical quality will come with more advanced technology and familiarization with its usage.⁵ As telehealth becomes a convention, implementation of clinical care standards will be helpful in not only establishing value but also tracking quality improvements in digital care delivery.²²

Naturally, provider concerns about technology arise not only from the vendor end but also the consumer side. Implementation of universal telehealth services will be challenged by the digital divide. Socioeconomic disparities continue to make vulnerable populations difficult to reach; telehealth is not a panacea and does have limitations in this respect.²³ Patients of low socioeconomic status, limited English and technology proficiency, rural habitations, and disabilities do not see the same benefits with telehealth.^24,25

Limitations include lack of access to appropriate hardware and sustainable infrastructure to take advantage of digital care delivery. The need and preference for telehealth are increasing from both patient and provider perspectives; however, the difficulty in addressing these common barriers continues to be a concern for providers, as indicated in our survey. This demonstrates that advanced systems cannot stand alone and they need to be coupled with community-specific blueprints to reach those most vulnerable.²³

Another concern cited by providers is the lack of reimbursements in place for providers and health care practices. These compensation restrictions have been in place even before pandemic-era usage of telehealth. Historically, Medicare coverage of telemedicine was limited to patients in rural areas. Temporary changes by the Centers for Medicare & Medicaid Services removed restrictions on location, payment parity, and eligible services; private insurers also adopted this model.^10,26

These reimbursement changes have allowed health care systems to invest in virtual care models, thereby exceeding the expected number of video visits by factors of four to five in many regions.^9,27 Although provider reimbursements for telehealth services have temporarily increased, it is uncertain if any of these modifications will be maintained by payers postpandemic. This continues to be a source of anxiety for providers.

For example, the State Medical Board of Ohio issued a recent update suggesting reinforcement of prior requirements that patients must be seen in person before telehealth is available to them.²⁸ Many telehealth waivers are set to expire in other states as well.²⁹ Provider concerns seem justified as a newer, value-based care model must be adapted to fit the virtual care demands of consumers.

DIGITAL HEALTH ADOPTION DURING COVID-19

At the beginning of the pandemic, telehealth became one of the only reasonable modalities in which patients could receive ambulatory medical attention, resulting in a surge of usage. Overall, consumer utilization of telehealth grew by nearly threefold in 2020, from 8% to 22%.¹ The literature has also described continuous satisfaction levels and decreased no-show rates.^2,15–17 Although patient interest was on the rise before the pandemic, COVID-19 served as a catalyst to prioritize this 21st-century health care approach as a top consumer demand.

It is notable that the reported favored settings of utilization coincide with not only provider opinion but also patient preference. Providers reported being most interested in using telehealth for direct-to-patient care and least interested in the emergency department and inpatient care. Telehealth in the direct-to-patient care setting taps into a consumer-centric market, and providers prefer an environment that augments the patient experience by making access to care more convenient and affordable. Specifically, many providers referenced the utility of digital care for behavioral health visits, follow-up visits for results, medication management, and self-monitoring of chronic conditions.

In prior surveys, patient preference similarly aligned with the outpatient setting for telehealth purposes.^2,16,17 Patient convenience coupled with minimal reductions in the quality of their health care allows virtual platforms to flourish in the outpatient setting.^2,30 Regardless of pandemic restrictions, telehealth offers clear benefits for the provider–patient relationship and promotes positive effects on continuity of care.^4,17,31

On the other hand, the least preferred settings, inpatient care and emergency department care, are those in which the acute nature of the visit may potentially supersede patient savings. Although limited, current literature finds that patient preference toward telehealth in the emergency department and inpatient settings is not unanimous.^32,33 Of those not satisfied with a virtual platform for acute care, physical examinations are listed as the primary limitation.³² Similarly, provider satisfaction with performing physical examinations through a telehealth platform is quite disparate.^34,35

All provider groups reported interest in telehealth usage following the easing of COVID-19-era restrictions. Overall, adult providers seemed to sustain postpandemic interest more compared with pediatric providers (average interest scores of 3.64 vs. 3.32, respectively). This may suggest various levels of utility among patient populations. For example, telehealth may not be suited to accommodate the unique needs of pediatric populations. Suggested barriers include involvement of caregivers during pediatric testing and difficulty with confidentiality.^36,37

With objective assessments, such as physical examinations, it may be difficult to have children cooperate in a virtual setting; this concern was echoed in the open-ended option of the survey, where many providers expressed hesitancy regarding the ability to provide appropriate physical examinations. Overall, this preference for telehealth in adult providers compared with pediatric providers speaks to limitations that may exist in different populations.

Considering the exponential growth of telehealth usage, the ramifications of these findings are important for providers, hospital systems, and patients alike. Among the qualitative suggestions given to improve telehealth, providers stressed the importance of continually optimizing telehealth platforms. Specifically mentioned were leveraging of technology to include previsit interaction (i.e., symptom or medication questionnaire), multidisciplinary group medical visits, browser compatibility, electronic medical record integration, screen sharing, and additional documentation capabilities.

LIMITATIONS

This Qualtrics survey was sent with the purposes of comparing feedback versus use in a research setting. As surveys are inherently subject to error and bias, it is possible that those who did not respond had varying perspectives. However, within our responses, there was considerable variation with regard to experience and specialty.

A second limitation is that the survey is based on questions about hypothetical interest after the COVID-19 pandemic as a follow-up survey was not available. However, considering the increase in frequency and confidence of telehealth technology, we believe the described interest level can translate to actual use extrapolated from the hypothetical results.

Understanding provider preferences in the past may help us understand future needs of different provider populations seeing patients in a multitude of care settings.

Conclusions

Health care systems have seen a dramatic surge in telehealth services since the beginning of the COVID-19 pandemic. Physician interest in telehealth within a large academic health system is based on a consumer-centric philosophy of patient care, including improved patient access to care, while common boundaries include technology and reimbursement uncertainties. These themes are consistent across specialties and sites of practice.

It is clear that despite concerns around quality and the need to manage patient privacy, providers are encouraged about the emerging virtual landscape. While a postpandemic future is hard to predict, today both provider and patient preferences appear to be aligned around the utility of telehealth.

Authors’ Contributions

D.B., C.I.C., B.Z., S.P., J.S., and B.D. were responsible for data analysis and manuscript writing. C.I.C. and B.D. were responsible for experimental design. All authors reviewed, edited, and approved the final version of the manuscript.

Disclosure Statement

The authors declare that there are no conflicts of interest.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.