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Providers at a Midwestern Academic System Report a Positive Experience with Telehealth During the COVID-19 Pandemic

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Introduction

In March 2020, health care systems were compelled to drastically modify operations to respond to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. To mitigate the spread of this airborne virus transmitted through respiratory droplets, directed health measures (i.e., stay-at-home orders and social distancing) were recommended,1,2 elective procedures were prohibited,3 and ambulatory clinics across the country rapidly adopted telehealth to continue providing patient care.4–7

Before COVID-19, site to site telehealth was utilized by patients living in remote and underserved areas according to Centers of Medicare and Medicaid Services (CMS) requirements including established patient status and travel requirements to the clinic.8 These restrictive CMS policies regarding reimbursement for telehealth visits were waived to support patient accessibility during the pandemic.8

Within weeks of this change, many health care systems asked their providers to use telehealth to provide care to patients.4,7 For the purposes of this discussion, we define telehealth as the use of synchronous audiovisual technology to provide patient care from site to home. This rapid implementation was both technologically and logistically difficult,7 and it is important to consider the impact this had on providers.

Although there was robust literature before COVID-19 with regard to providers’ attitudes toward telehealth technology,9–11 or incorporating remote monitoring technologies into routine health care,12 there were few studies that surveyed providers who had used synchronous telehealth visits regarding their experiences13,14 or satisfaction15 with telehealth. Since the onset of COVID-19, there have been several studies in which providers have started sharing their experiences with telehealth.7,16–19 However, there are few formalized surveys that assess providers’ perceptions of their ability to develop adequate rapport with the patient19,20 or their ability to conduct an appropriate physical examination.19,21

The purpose of this study was to understand providers’ perceptions of their ability to perform clinical assessments, physical examinations, and connect with patients over a digital platform, along with discerning what type of patients may be best suited to telehealth at our institution. The results of this survey are consistent with recent publications and are presented here to contribute to the growing body of literature on provider experiences with telehealth.

Methods

Nebraska Medicine is a large midwestern health care system affiliated with the University of Nebraska Medical Center. There are ∼1,000 physicians and 500 advanced practice providers (APPs) distributed among 2 hospitals and ∼40 primary and specialty care ambulatory locations. The system uses Epic® for their electronic health record.

Anonymous surveys were sent to 944 physicians and APPs across the health care system for a 2-week period in October 2020. Any attending physician or APP who engaged in telehealth in a clinical setting was invited to respond to the survey. Fellows and resident physicians were excluded from the study. The respondents were grouped according to their primary medical or surgical specialties. Family medicine and internal medicine providers were categorized as primary care. Providers who indicated they were primarily in the fields of allergy, immunology, cardiology, dermatology, endocrinology, hematology/oncology, infectious disease, nephrology, neurology, pulmonology, or rheumatology were grouped together as medical subspecialties.

The surgery group included providers from specialties including general surgery, neurosurgery, OBGYN, ophthalmology, oral maxillofacial surgery, otolaryngology, or urology. Psychiatry providers were listed in the category of mental health. If a respondent chose “other” and wrote in their subspecialty, they were categorized at the author’s discretion into one of the aforementioned groups. If the respondents did not provide a write-in response, or chose not to identify their specialty, they were included in the “other/chose not to respond” group. No pediatric providers responded to the survey.

The survey (Supplementary Appendix SA1) included demographic questions and a combination of open and closed ended questions regarding providers’ experience with telehealth visits. The providers were asked to express their responses as a percentage of visits in which the statement applied to them, or as a scale of agreement ranging from strongly agree to disagree. The survey was edited, reviewed for content validity, and approved by three committees including a group of physician and APP representatives spanning 15 specialties, the telehealth Committee, and the academic clinical chairs. The survey was pilot tested and edited for clarity before deployment through email from the senior medical director of care experience.

This study was approved by the internal review board (IRB No.: 630-20-EX). Study data were collected and managed using REDCap (Research Electronic Data Capture).22 Descriptive statistics were performed using IBM SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, NY).

Results

A total of 178 health care providers (18.9% response rate), including attending physicians, nurse practitioners, and physician assistants, completed the survey (Table 1). The majority (62.1%) of respondents were physicians (MD or DO), 20.9% were nurse practitioners, 10.2% were physician assistants, and 6.8% selected the “other” category. In total, 31.5% of respondents were sorted into the medical subspecialty category, 28.7% primarily worked in primary care, 14.6% were mental health providers, 16.3% were primarily surgical, and 7.9% of respondents selected other or chose not to answer. There was a wide variety of duration of practice within our responding providers. In total, 33.9% of respondents had been in practice for 5 years or less, whereas 20.9% of respondents had been in practice for >20 years.

Table 1. Provider Demographics
PROVIDER ROLE MEDICAL AREA DURATION OF PRACTICEa
  n %   n %   n %
MD/DO 110 62.1 Medical subspecialty 56 31.5 0–5 years 60 33.9
APRN-NP 37 20.9 Primary care 51 28.7 6–10 years 43 24.3
PA-C 18 10.2 Mental health 26 14.6 11–15 years 21 11.9
Other 12 6.8 General surgery or surgical subspecialty 29 16.3 16–20 years 16 9.0
      Other/choose not to answer 14 7.9% >20 years 37 20.9

Nearly 9 in 10 (88.3%) respondents indicated they had no telehealth involvement in their clinics before COVID-19. The use of telehealth visits drastically increased during the pandemic; 98.8% of providers indicated they were currently using telehealth in some capacity, with 33.4% of providers indicating that over half of their clinics were currently conducted through telehealth. Only 0.6% of responders, all of whom were from the medical subspecialties group, indicated that telehealth was not well suited to their practice in any capacity. These respondents comprised 1.8% of all respondents in the medical subspecialties group.

Nearly half (48.7%) of all respondents felt their practice lent itself well to telehealth visits in all, almost all, or most instances. Looking forward, only 2.4% of providers stated they had no desire to use telehealth in a postpandemic setting. Conversely, among all survey respondents, 97.6% of providers reported they want to use telehealth in some capacity after the pandemic’s resolution (please see distribution among specialty groups in Fig. 1).

Fig. 1.

Fig. 1. Percentage of survey respondents selecting percentage of future visits preferred to be telehealth, by specialty group. Date of survey: October 2020. One hundred seventy-eight survey respondents.

On the survey, providers were asked to express the percentage of telehealth visits (0–25%, 26–50%, 51–75%, or 76–100% of visits) in which they were able to complete a series of statements. In total, 86.8% of providers chose either of the upper two quartiles in response to the statement, “I felt able to adequately address the patient’s chief complaint” (Fig. 2). In total, 86.6% of respondents “Felt confident in their assessment of the patient’s clinical issue,” and 86.1% of respondents indicated they were “Able to form an adequate personal connection with the patient during telehealth visits” in over half the visits. Providers’ responses to the statement, “I felt able to adequately complete the necessary physical exam during telehealth visits,” were more widely distributed as shown in Figure 3.

Fig. 2.

Fig. 2. Percentage of survey respondents selecting percentage of telehealth visits in which they felt able to adequately address the patient’s chief complaint, by specialty group. Date of survey: October 2020. One hundred seventy-eight survey respondents.

Fig. 3.

Fig. 3. Percentage of survey respondents selecting percentage of telehealth visits in which they felt able to complete the necessary physical examination, by specialty group. Date of survey: October 2020. One hundred seventy-eight survey respondents.

In response to the statement, “Telehealth visits are typically an effective replacement for new patient visits,” 58.5% of respondents disagreed and 15.1% were neutral. With regard to the statement, “Telehealth visits are typically an effective replacement for follow up visits with established patients,” 83% of respondents either agreed or strongly agreed, 9.4% were neutral and 7.5% disagreed.

Providers indicated several logistical areas on their surveys in which they felt there could be improvement. Specifically, they reported that during telehealth visits, support staff only performed medication reconciliation in 46.1% of visits, reviewed allergies in 31.5% of visits, reviewed social, medical, and family history in 14.6%, 14%, and 10.1% of visits, respectively, and performed a review of systems in 9.6% of visits. Other logistical issues that were reported included patients being scheduled incorrectly (7.6%), having the wrong chief complaint listed (10.7%), or not being signed up to use the telehealth technology at the time of the visit (18.2%).

From a technological perspective, survey respondents reported video quality issues in 27.5% of visits, audio issues in 16.8% of visits, and software issues in 11.9% of visits. Survey respondents noted they felt inexperienced with the technology during 34% of visits. In 24.4% of visits, these technology issues were severe enough, providers needed to convert an audiovisual appointment to a telephone appointment.

Discussion

Overall, our data show a widespread increase in the number of telehealth visits that is consistent with nationwide trends.4,7 In addition, survey respondents felt they were adequately able to address the chief complaint and form personal connections with their patients in most visits, but the ability to perform an adequate physical examination was less consistent. Our providers felt established patients were very suitable for telehealth visits, and generally felt that telehealth was not an adequate replacement for an in-person visit for a new patient.

Before the pandemic, barriers to adoption of telehealth technology were wide ranging, and included cost of adoption of new systems, a steep learning curve with new technology, resistance to change by providers, interstate licensing and institutional credentialing of physicians, creating system infrastructure, designing clinical processes, and receiving adequate reimbursement.23 However, there was not widespread concern that telehealth would be hampered by providing impersonal care to patients.23 This is consistent with the results of our survey in which 86.1% of our respondents felt they were able to establish an adequate personal connection with their patients in the majority of telehealth visits.

In other similar surveys, 64.7% of medical and surgical providers21 and 67–88% of mental health providers20 also felt they were able to develop rapport with unimpaired communication during telehealth visits. In addition, a survey conducted during the COVID-19 pandemic reported that clinicians felt in-person visits were comparable in quality with telehealth visits.16

In surveys conducted during the COVID-19 era, the largest barrier to implementing telehealth visits seems to be the issue of completing a physical examination.18,19 What providers define as an “adequate physical exam” during a telehealth visit will be widely dependent on the reason for the visit and for what problem the patient is being seen. For example, a patient following up for a medication check or reviewing imaging may not require much of a physical examination, whereas a new patient may need a more thorough examination.

Only 20% of our survey respondents felt they were able to complete an adequate physical examination in over 75% of their visits. Comparably, two other surveys also conducted during the pandemic reported difficulty with completion of the physical examination. In one survey, 29% of providers agreed or strongly agreed they were able to complete a sufficient clinical examination,21 and in the other survey, 29.9% of providers endorsed their inability to complete a physical examination as a significant barrier to their usage of telehealth.19

It is exciting that so many of our providers wish to continue using telehealth in the future, and the breakdown of specialty responses is telling of the way in which this may be incorporated (Fig. 1). Mental health providers wish to have the largest amount of telehealth incorporation into their practice, with only 19.2% of providers wanting telehealth to make up less than a quarter of their practice. This is a slightly lower response rate than the 95.5% of mental health providers in a similar survey that wanted at least a quarter of their practice to be telehealth.24

To the contrary, 75.8% of surgeons hope that less than a quarter of their clinical practice is telehealth. Medical subspecialties and primary care fall in the middle, but still trend toward having less than a quarter of their practice be represented by telehealth. In a recent similar survey, physicians indicated they felt 44.9% of total visits should be conducted through telehealth in a postpandemic setting.16 It is important to consider that although telehealth is a valuable technology, it does not completely replace the traditional practice of seeing patients in person. Rather, it is an augmentation tool that can be used to supplement medical and surgical practices for certain predetermined situations such as follow-up visits.14

In our survey, 58.5% of respondents felt telehealth was not effective for new patients and 83% of respondents either agreed or strongly agreed that telehealth was an effective replacement for follow-up visits. A survey in 2019 that looked at telehealth follow-up visits for established patients reported that 59% of clinicians felt there was no difference in the quality of an in-person visit compared with a telehealth visit.14 In total, 52.5% of those clinicians also felt that telehealth for established follow-up patients was a more efficient use of their time.14 Given these data, it may be reasonable to continue usage of telehealth for follow-up visits at a higher rate than for new patients, but this will likely be provider or department dependent.

Now that telehealth has been so widely adopted and integrated, it is imperative to focus on how best to support and train staff to continue using this technology moving forward.25 Our survey respondents indicated they felt inexperienced with technology in nearly one-third of visits. This may be a result of our institution only having a single training module for providers before the start of telehealth visits at the onset of the pandemic. Many providers are technologically adept and had no issues with learning the system, but for those providers who struggle with technology, it is critical to have a supportive technical staff, solid provider infrastructure, and formal training modules to supplement their experience.

Our providers identified several logistical opportunities in the “previsit preparation” to improve their experience with telehealth. During in-person clinic visits at our institution, it is routine for medical assistants or nursing staff to complete medication reconciliation, review of systems, and review of family, social, and medical and allergy histories before the visit, however, this was not routinely being done in a telehealth setting. Instead, this task was falling to providers, which led to a decrease in efficiency, or sometimes simply did not get done.

It is important to note that many telehealth visits are among established patients and taking a full history may not be necessary for these patients. We recognize that the needs of different departments will vary widely, and that for successful future telehealth, it will be important for each department, or perhaps each individual clinician, to standardize their telehealth check-in process and ensure they have the appropriate staff available to complete the process. This will likely require a multiteam approach with members of information technology and clinical operations teams working closely with those providers experienced in telehealth.

LIMITATIONS

We recognize this survey was conducted at a single health care organization in a midwestern location, which is not necessarily representative of providers in other geographic areas, or perhaps even of providers in differing health systems within the midwest. In addition, this survey is a snap-shot in time of providers’ perceptions of telehealth early in the COVID-19 pandemic. We recognize that providers’ perceptions are fluid, and they may hold different opinions now that telehealth has been in use longer, or that the opinions and needs of their patients have continued to evolve with time.

Conclusions

It is difficult to know what the future of telehealth will be as state and federal legislative decisions regarding credentialing and reimbursement are still developing. Incorporating telehealth into daily clinical practice during the COVID-19 pandemic has helped maintain appropriate care during this global crisis, and providers at our institution have had positive experiences thus far with the technology. In the future, telehealth may be more widely accepted not just as a crisis solution, but also an advancement in the health care system that will continue to provide meaningful and more accessible care to patients.

Authors’ Contributions

J.B., K.C., and S.R. contributed to the project concept, design, implementation, data acquisition, data analysis, and review. J.B. drafted the initial article; all authors contributed to its revising, review, and approved the final article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix SA1

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