Experience With and Awareness of Telemedicine Among Korean Outpatients During the COVID-19 Pandemic

Introduction

Telemedicine is the use of electronic information and communications technologies to provide health care from a distance.¹ In telemedicine, physicians and patients communicate through secure communication technologies, such as telephone, secure e-mail, portals within electronic medical records systems, or online audio or video calls.² There has been growing interest in the use of telemedicine as a means of health care delivery. This is partly because technological advances have made digital devices less expensive and easier to use and because there is a need to find alternative health care delivery systems as health care costs and patient expectations have increased.³

Coronavirus disease 2019 (COVID-19) has affected health care worldwide.⁴ Providing health care during this pandemic has been challenging due to the lockdown and risk of infection spread.⁵ Cancellation and postponement of in-person visits have been reported in many medical centers.⁶ To mitigate the difficulties of face-to-face treatment under these circumstances, telemedicine has been adopted as a safer means of providing health care during the COVID-19 pandemic,⁷ and physicians have been providing medical care using telemedicine and virtual services.⁸ In Korea, telemedicine has not previously been permitted by law. However, limited to stable patients to assure safety, consultation and prescription through telephone have been temporarily permitted as of February 2020 due to the COVID-19 pandemic.⁹

According to previous studies, most patients were satisfied with their telemedicine experiences.^10–12 Several sociodemographic characteristics were associated with access to and satisfaction with telemedicine. Females, patients with a high level of education,¹² patients in metropolitan areas,¹³ and patients with cost barriers to visiting clinic¹⁴ preferred telemedicine; however, older adults, rural area residents, patients with a low level of education,¹⁵ Asian patients, and non-English–speaking patients¹⁶ were not as satisfied with telemedicine. In a previous Korean study, >80% of patients indicated reliability, satisfaction, and future demand as associated with telemedicine.¹⁷ Furthermore, high accessibility, care effectiveness, ease of use, usefulness, and privacy were decisive factors affecting telemedicine acceptance in the general Korean population.¹⁸

Few studies have explored the experience with and awareness of telemedicine in Korea. Furthermore, it is necessary to evaluate the possibility of using telemedicine after the COVID-19 pandemic as well as the implications that can be derived from current experiences in telemedicine. Therefore, we evaluated experience, satisfaction, and preferences regarding telemedicine and investigated considerations for the future use of telemedicine among Korean outpatients.

Methods

Study Participants

Study participants were consecutively enrolled by six family physicians from four hospitals between December 2020 and March 2021. Among the patients who visited outpatient clinics of the department of family medicine during the study period, 570 patients from 4 hospitals agreed to participate in the study. Among them, 7 participants did not respond to the question asking about their experience with telemedicine, leaving 563 participants (237 men and 326 women) for the final analysis. All of the participants provided written informed consent before participating in the study. The study was conducted following the Declaration of Helsinki, and its protocol was approved by the Asan Medical Center Institutional Review Board (S2020-2642-0001) in Seoul, Korea.

Data Collection and Measurement

All physicians collected data using questionnaires, which included questions regarding sociodemographic characteristics and knowledge, experience, satisfaction, preference, and future considerations for telemedicine. The sociodemographic characteristics included age, gender, educational levels, monthly household income, and residential area. The educational levels of the participants were classified as middle school graduate and below, high school graduate, and college graduate and above. Monthly household income was categorized as <2 million Korean Won (KRW), 2–3.99 million KRW, 4–5.99 million KRW, and ≥6 million KRW. Residential areas were divided into metropolitan city areas, urban areas, and suburban areas.

Knowledge, Experience, and Satisfaction with Telemedicine

Participants’ knowledge of telemedicine was evaluated with the following two sentences: “Telemedicine is the practice of medicine in which medical information or medical service is provided using information communication technology from a distance” and “Due to the COVID-19 pandemic, if there is a request from re-visit patients who have scheduled in advance, it is possible to provide telephone consultation and prescription based on the doctor’s discretion.” Participants were asked to choose one from the following response options: “yes,” “no,” or “not sure.” Participants who answered “yes” to both sentences were defined as knowing telemedicine.

Participants’ experience of telemedicine was evaluated by the following question: “Have you experienced telemedicine since March 2020?” Those who answered “yes” were further asked to provide information on the method(s) of telemedicine, type(s) of disease(s), and content of the consultation. Method of telemedicine was classified as telephone consultation, video consultation, text message/messenger, and others.

Type of disease for telemedicine was categorized as a chronic disease (hypertension, diabetes, dyslipidemia, osteoporosis, etc.), acute condition (common cold, abdominal pain, diarrhea, etc.), psychiatric disorder (depression, anxiety, insomnia, etc.), and health screening. Content of the consultation included consultation for symptoms, prescription for a chronic disease, checking test results, and referral, appointment, or scheduling an examination.

Satisfaction with the telemedicine experience was evaluated with the following eight questions: “Overall, I was satisfied with the telemedicine,” “Telemedicine saved time and cost for hospital visits,” “It was good that there was no risk of infection,” “During telemedicine, the doctor explained well what I wanted to know,” “Telemedicine was effective in the treatment of diseases,” “During telemedicine, I received care for a sufficient amount of time,” “The telemedicine method was convenient to use,” and “Telemedicine was better than in-person consultation.” The response options were “strongly disagree,” “disagree,” “not sure,” “agree,” and “strongly agree.” Respondents who answered “agree” or “strongly agree” were defined as being satisfied with telemedicine.

Preference and Future Considerations for Telemedicine

Participants were asked to provide their preference for methods of consultation regarding the following occasions: first consultation for mild acute symptoms (common cold, headache, etc.), reconsultation for mild acute symptoms, first consultation for emergency acute symptoms (severe headache, paralysis, etc.), reconsultation for emergency acute symptoms, first consultation for chronic disease (hypertension, diabetes, etc.), reconsultation for chronic disease, management of psychiatric disorder, and diseases requiring a doctor’s physical inspection, such as dermatological diseases. Response options included in-person consultation, telephone consultation, video consultation, and others.

Regarding future considerations related to telemedicine, participants were asked whether they would agree with the following four statements: “I hope a system for telemedicine is in place,” “I hope that telemedicine is effective in treating diseases,” “I hope that the communication between the doctor and the patient is good in telemedicine,” and “I wish to continue receiving telemedicine.” The response options were “strongly disagree,” “disagree,” “not sure,” “agree,” and “strongly agree.” Participants who answered either “agree” or “strongly agree” were considered to agree with the respective item.

Statistical Analyses

Descriptive statistics were used to present the sociodemographic characteristics and knowledge of, experience with, satisfaction with, preference for, and future considerations regarding telemedicine of the study participants. The chi-square test was used to compare participants’ sociodemographic characteristics as well as their preference for and future considerations regarding telemedicine according to their telemedicine experience.

Multivariate logistic regression analysis was used to investigate factors related to overall satisfaction with telemedicine. The odds ratios (ORs) and 95% confidence intervals (CIs) for satisfaction with telemedicine were calculated after adjusting for age, gender, educational level, household income, residential area, and knowledge and methods of telemedicine. All analyses were performed using IBM SPSS statistics for Windows, version 24.0 (IBM Corp., Armonk, NY), and p < 0.05 was considered statistically significant.

Results

Basic Characteristics of the Study Participants

Table 1 presents the basic characteristics of the study participants. Among the 563 participants, 364 (64.7%) participants had experience with telemedicine. The distributions of age, residential area, and knowledge of telemedicine were significantly different between participants with and those without experience with telemedicine. The proportions of participants aged ≥65 years, those residing in a metropolitan city, and those with knowledge of telemedicine were greater among those with telemedicine experience. In both groups, more than half of the study participants were female, and about two-thirds of participants had a level of education of college graduation or higher. More than half of the study participants had a monthly household income of ≥4 million KRW.

Experience and Satisfaction with Telemedicine

Table 2 presents participants’ experience and satisfaction with telemedicine during the COVID-19 pandemic. More than 95% of telemedicine was performed by telephone consultation, whereas <1% was completed by video consultation. The most common disease type for telemedicine was chronic diseases (67.5%). Few participants (3.1%) used telemedicine for psychiatric disorders.

The most common content of virtual consultation was prescribing medication for a chronic disease (47.5%). Approximately 33% of the participants used telemedicine to check their test results, and 18% used telemedicine for consultation regarding symptoms. Overall, 82.4% of the study participants reported that they were satisfied with telemedicine. More than 90% of the participants were satisfied with telemedicine for saving time and money relative to hospital visits, no risk of infection, and convenience.

Factors Associated with Satisfaction with Telemedicine Experience

The factors associated with overall satisfaction with telemedicine experience are presented as adjusted ORs and 95% CIs in Table 3. Compared with participants aged ≤39 years, those aged ≥65 years had higher odds (OR 3.53, 95% CI 1.44–8.68) of satisfaction with their telemedicine experience. Metropolitan city residents had higher odds (OR 6.8, 95% CI 1.41–32.55) of satisfaction with telemedicine than suburban residents. Compared with participants with no knowledge of telemedicine, those with knowledge (OR 2.96, 95% CI 1.21–7.26) were more likely to be satisfied with their telemedicine experience.

Preference for Telemedicine

Table 4 presents participants’ preference between telemedicine and in-person visits in various medical situations according to their telemedicine experience. For chronic diseases, participants with telemedicine experience significantly preferred telemedicine for revisits, compared with those with no telemedicine experience. For emergency acute symptoms, participants with telemedicine experience tended to prefer telemedicine for revisits with marginal statistical significance (p = 0.065). For psychiatric disorders and diseases requiring a doctor’s physical inspection, in-person visits were preferred regardless of telemedicine experience.

Future Considerations Regarding Telemedicine

Table 5 presents the future considerations regarding telemedicine according to participants’ telemedicine experience. Most participants agreed that telemedicine needs improvement. Compared with participants with no telemedicine experience, those with telemedicine experience responded that establishing a system for telemedicine is required with marginal statistical significance (p = 0.053).

Discussion

In our study, >80% of the study participants were satisfied with their telemedicine experience. Patients of older ages, those residing in a metropolitan city, and those who knew telemedicine were more likely to be satisfied with telemedicine than their counterparts. Telemedicine was primarily used for the management of chronic diseases and was less likely to be preferred for psychiatric disorders and diseases requiring a doctor’s physical inspection. Furthermore, most participants recognized the need for future improvement in telemedicine.

Telemedicine was performed primarily through telephone in our study population. This was partly because patients were not familiar with the novel methods,¹⁹ missed the human interaction with a doctor,²⁰ or were concerned about their privacy and the security of the data.²¹ Moreover, in Korea, telemedicine had not previously been allowed under the Medical Act²²; however, telephone counseling and prescriptions have been temporarily allowed since February 24, 2020, during the COVID-19 pandemic.⁹ Therefore, practical systems for telemedicine have not been developed except for a simple telephone consultation.

Telemedicine was primarily used for the management of chronic diseases and health screenings. This is consistent with a previous study showing the positive effect of telemedicine on the monitoring of chronic diseases.²³ In addition, a considerable proportion of telemedicine was used for simple care. This may be because telemedicine is more effective in uncomplicated cases, as shown in previous studies,^24,25 and simple care has a low risk of invasion of privacy. Active use of telemedicine for these issues can reduce the burden of on-site work and medical costs.²⁶ Furthermore, telemedicine would enable efficient use of medical capacity in other areas of medicine.

Participants’ satisfaction with their telemedicine experience was consistent with other studies.^10,17 However, their relative satisfaction with telemedicine compared with in-person visits was lower than their absolute satisfaction, suggesting that telemedicine needs to supplement the advantages of face-to-face treatment in the future. According to previous studies, factors related to satisfaction with telemedicine were transportation and the cost to a hospital visit, residential areas, age, education or income levels, gender, and race.^13–16 In our study, older age, metropolitan city residents, and knowing telemedicine were significantly associated with higher satisfaction with telemedicine experience.

Older adults were more satisfied with telemedicine because they are more vulnerable to infection and may feel uncomfortable visiting hospitals during the COVID-19 pandemic. Furthermore, telephone consultation is easy to use. One of the reasons for high satisfaction among metropolitan city residents is that they have better access to medical care; thus, they tend to have more experience with telemedicine. In addition, participants with knowledge of telemedicine were more satisfied with telemedicine as they were more likely to perceive its benefits through previous experience.

Telemedicine was preferred in cases with a low degree of emergency and for the management of chronic diseases. This is because telemedicine is effective for monitoring and follow-up of certain medical conditions.^27,28 In contrast, telemedicine was not preferred in medical situations in which privacy or a physician’s inspection was required. Telemedicine has limitations in terms of the lack of physical examination,¹¹ and privacy is negatively correlated with public attitude toward telehealth.¹⁸ However, accessibility, ease of use, and enhanced care were reported to increase telehealth acceptance.¹⁸

Consistent with the results, most participants responded that establishing a system for telemedicine as well as enhanced care effectiveness and communication are required in the future. In many countries, telemedicine has not been established among users owing to political, technical, legal, and social factors.²⁹ Telemedicine faces obstacles related to the availability of necessary infrastructure, inadequate funds, and lack of experience.³⁰ Therefore, it is necessary to gradually build a practical system and broaden the application area for telemedicine so that its advantages can be utilized in various medical situations.

This study has several limitations. First, the proportion of telemedicine experience should be interpreted with caution as the study participants are restricted to patients visiting outpatient clinics of the department of family medicine in four hospitals; therefore, they are not nationally representative. Second, as this study was cross-sectional, causal relationships between patient characteristics and satisfaction with telemedicine could not be identified. Third, although the analysis adjusted for variables that can influence satisfaction with telemedicine experience, there may have been other potential factors affecting the outcome. A large longitudinal study investigating experiences with—and awareness of—telemedicine, using a nationally representative sample, is required.

Conclusions

The COVID-19 pandemic has required a change in health care delivery, necessitating reliance on telemedicine. In this study, most participants had a high degree of satisfaction with telemedicine. Older age, living in a metropolitan city, and knowledge of telemedicine were significantly associated with satisfaction with telemedicine. Participants preferred to use telemedicine in cases with a low degree of emergency and acuteness, particularly managing chronic diseases and simple care. Furthermore, most patients hoped for continued use of telemedicine in the future and improvements for it. Telemedicine can be used in applicable medical situations in the future and for that, building the infrastructure is necessary in Korea.

Authors’ Contributions (Use CRediT terms)

Conceptualization of the study was done by S.S., W.S.C., C.K., Y.K.P., S.P.J., and Y.S.K. Data curation was done by S.S., W.S.C., C.K., Y.K.P., S.P.J., and Y.S.K. Formal analysis was carried out by S.HK. Methodology of the study was taken care of by S.H.K., S.Y.K., and Y.S.K. Software was taken care ofY.S.K. Validation was done byY.S.K. Investigation was carried out by S.S., W.S.C., C.K., Y.K.P., S.P.J., and Y.S.K. Writing—original draft—was by S.H.K. Writing—review and editing—was by S.Y.K and Y.S.K.

Disclosure Statement

All authors have no potential conflicts of interest.

Funding Information

There was no source of funding for this research.