Perspectives of Patients and Providers on the Use of Telemedicine for Chronic Disease Specialty Care in the Alaska Tribal Health System

Rural Patients' Experiences with Synchronous Video Telehealth in the United States: A Scoping Review

Background: Telehealth can help increase rural health care access. To ensure this modality is accessible for rural patients, it is necessary to understand rural patients' experiences with telehealth. Objectives of this scoping review were to explore how rural patients' telehealth experiences have been measured, assess relevant research, and describe rural telehealth patient experiences. Methods: We searched five databases for articles published from 2016 through 2022. Primary research reports assessing rural adult patient experiences with synchronous video telehealth in the United States in any clinical area were included. Data collected pertained to study characteristics and patient experience assessment characteristics and outcomes. Quality of included studies was assessed using the Quality Assessment with Diverse Studies tool. Review findings were presented in a narrative synthesis. Results: There were 740 articles identified for screening, and 24 met review inclusion criteria. Most studies (70%, n = 16) assessed rural telehealth patient experience using questionnaires; studies employed interviews (n = 11) alone or in combination with surveys. The majority of surveys were study developed and not validated. Quantitative patient experience outcomes fell under categories of patient satisfaction, telehealth care characteristics, patient-provider rapport, technology elements, and access. Qualitative themes were most often presented as telehealth benefits or facilitators, and drawbacks or barriers. Conclusions: Available research indicates positive patient experiences with rural telehealth services. However, study weaknesses limit generalizability of findings. Future research should apply established definitions for participant rurality and clearly group samples by rurality. Efforts should be made to use validated telehealth patient experience measures.

Healthcare Providers’ Experience Using Telehealth During the Onset of the COVID-19 Pandemic in a Predominantly Rural Patient Base: An Online Survey

INTRODUCTION

COVID-19 led to the rapid adoption of telemedicine with a significant spike in the literature concerning the patients' perspective of its use. The providers' perspective has been less well studied. Med Center Health is a healthcare network that provides services in 10 southern Kentucky counties that are home to over 300,000 people with approximately 61% of this population living in areas defined as rural. The goal of this article was to compare the experience of providers serving a predominantly rural population to their patients and compare the experience of providers between each other based on the obtained demographic data.

METHODS

An online electronic survey was developed and sent out from July 13th, 2020 to July 27th, 2020 for completion to the 176 physicians of the Med Center Health Physician group. The survey gathered basic demographic information, telemedicine use during COVID-19, and perceptions of telemedicine use during and the role of telemedicine after COVID-19. Perceptions of telemedicine were gauged using Likert and Likert-style questions. Cardiology provider responses were compared to the previously published patient responses. Differences between providers were also analyzed based on the demographic data obtained.

RESULTS

Fifty-eight providers responded to the survey with nine providers indicating that they did not use telemedicine during COVID-19. Significant differences between eight cardiologists' and cardiology patients' perceptions of telemedicine visits were seen for internet connectivity (p < 0.001), privacy (p = 0.01), and clinical exam (p < 0.001) with cardiologists ranking these as more concerning or worse in all instances. These results continued when comparing perceptions of patients' in-person experience and providers' perception of telemedicine visits with significant differences observed with clinical exam (p < 0.001), communication (p = 0.048), and overall experience (p = 0.02). No statistically significant differences were seen between cardiologists and other providers. Providers who indicated more than 10 years of practice rated their experience with telemedicine significantly lower in the domains of effective communication (p = 0.004), level of care provided (p = 0.02), thoroughness of clinical exam (p = 0.047), patient comfort discussing concerns (p = 0.04), and overall experience (p = 0.048). Despite this, only three providers indicated that they would not use telemedicine post-pandemic with a majority indicating that they would feel comfortable using telemedicine for follow-up visits and medication refill visits.

CONCLUSION

This is the first study to our knowledge to compare patient and provider satisfaction concerning telemedicine across a wide array of topics using Likert-style and Likert scale questions and the first to investigate the perception of providers who serve a predominantly rural patient base during the COVID-19 pandemic. Similar results have been found in a few previous studies concerning telemedicine being less favorably rated by more experienced providers. Further studies need to be conducted to identify and correct the barriers that exist for providers and the adoption of telemedicine.

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States

INTRODUCTION

Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships.

METHODS

A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively.

RESULTS

A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue.

CONCLUSION

This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.

Health care utilization in Alaska Native people receiving chronic disease specialty care by videoconsultation compared to propensity-matched controls

INTRODUCTION

Previous studies have had mixed findings about the effects of telemedicine on health care utilization. We designed this study to assess differences in health care utilization between ever users of telemedicine for chronic disease specialty care compared to propensity-matched controls.

METHODS

This observational study of usual care in the Alaska Tribal Health System evaluated telemedicine use (videoconsultation) and healthcare utilization using data from the electronic medical record between 1 January 2015 and 30 June 2019. Eligibility criteria included: age 18 and older, chronic condition diagnosis, and residing in one of four study regions. Cases had ever used telemedicine while controls had not. We used propensity score matching to achieve covariate balance between cases and controls, and then estimated the effect of telemedicine on outcomes using multivariable models. Outcomes included rates of hospitalizations, outpatient visits, and emergency department visits.

RESULTS

Cases (ever users of telemedicine) had higher hospitalization rates (rate ratio 1.31, p < 0.01) and higher outpatient visit rates (rate ratio 1.23, p < 0.01). Cases had lower rates of emergency department visits, though non-statistically significant (rate ratio 0.87, p = 0.07). Cases were more likely than controls to have no emergency department visits per follow-up time (49% vs 36%, p < 0.01).

DISCUSSION

We found higher rates of inpatient and outpatient health care utilization in people who had ever used telemedicine compared to propensity-matched controls, with potentially lower rates of emergency department visits. These findings contribute to the literature on telemedicine and should be considered in the context of other factors influencing telemedicine use and outcomes.

Impact of Hearing Loss on Communication During Remote Health Care Encounters

Introduction: Satisfaction with telemedicine is generally high; however, it can lead to communication problems for people with hearing loss (HL), especially when encounters are conducted by telephone, because of the inability to see the face and lips on which many people with HL rely. Despite acknowledgement that HL might affect telemedicine outcomes, no studies have directly examined this. The primary aims of this study were to determine whether and how HL impacts patient satisfaction and willingness to use telemedicine. Methods: Opinions about telemedicine were assessed in a survey of 383 members of the general public. Data regarding reported hearing ability, use of hearing assistive technology, and preferred form of communication (oral/aural vs. sign language) were also collected; people with HL were intentionally oversampled. Survey items included closed set and open-ended responses. Results: People with HL declined the offer of telemedicine appointments, rated telemedicine outcomes significantly less positively, and had stronger preferences for in person care than did people without HL. Explanations provided for this were directly associated with hearing-related difficulties or the indirect consequences of those difficulties. HL resulted in concerns about communication during the appointment, a lack of privacy when an intermediary helped with communication during the appointment, worries that critical information has been misheard/missed, and anxiety/stress. Conclusions: The needs of people with HL during telemedicine encounters must be addressed to ensure equitable access. Health care providers should take responsibility to communicate clearly with people with HL and individuals with HL should be willing to advocate for their needs and use special access tools during telemedicine appointments.

Clinician Preferences for Current and Planned Future Use of Telemedicine

Introduction: Many clinicians and patients tried telemedicine for the first time during the COVID-19 pandemic. In a prior survey, we found that clinicians who were adaptable and willing to incorporate technology into their clinical practice are more likely to utilize telemedicine. Seeking factors associated with current and future use of telemedicine, and identifying its relative advantages and drawbacks, may help determine the role of telemedicine after the pandemic. Questions/Purposes: We asked (1) which demographic factors and personal preferences are associated with current and planned future use of telemedicine, (2) what factors are associated with telemedicine utilization, and (3) what are clinician-reported advantages and disadvantages of telemedicine? Materials and Methods: Approximately 750 clinicians within a national multispecialty hospital group were invited to complete an online survey assessing telemedicine use and preferences, self-reported technology proficiency, and personal characteristics. A total of 284 clinicians started the survey, and 259 complete responses were analyzed using bivariate analysis and multivariable regression. Results: More frequent current telemedicine use was associated with being a nonsurgeon clinician, not primarily practicing in an inpatient setting, preferring either telemedicine or having no preference for discussing sensitive topics, and greater self-reported technological proficiency. Planned future telemedicine use was associated with greater self-reported troubleshoot ability and less desire for a hands-on physical examination. Clinicians reported that the top benefits of telemedicine are decreased barriers for patients and convenience for clinicians, and disadvantages are technical difficulties for both patients and clinicians. Conclusions: Telemedicine continues to be widely utilized by clinicians, particularly those who are confident in their ability to examine patients over video, and who can troubleshoot issues that arise on the platform. With continued reimbursement, telemedicine is likely to remain a convenient and effective method of caring for patients.