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The COVID-19 pandemic forced medical practices to rapidly change their in-person visits to virtual ones, but how do their patients feel about these new forms of health care?
In a recent study published in Urology,1 a survey-based assessment of varied telemedicine experiences was evaluated by a group of investigators led by Kara L. Watts, MD. Watts is an associate professor of the department of urology at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
In the COVID-19 pandemic, we launched a brand-new telehealth program in our urology department here at Montefiore Medical Center. We didn't have any telemedicine within our department prior to the pandemic, although other medical departments within the institution did conduct some telemedicine visits. We wanted to use this opportunity to evaluate and understand how it was being perceived by our patients. We found, pretty much immediately upon launching our telehealth program, that there were a lot of challenges in our particular patient population related to how they were adopting the traditional form of telehealth, which is typically defined as a video visit. This requires either Wi Fi or 4G, some broadband access, and a smart device, and a lot of our patients lack those capabilities. So, a lot of our visits were actually being conducted by phone visits, which we were able to bill for as well as proceed with because of emergency waivers from the Centers for Medicare & Medicaid Services during the pandemic. It was a nice opportunity to look at how this was affecting and being perceived by our patients.
We called a lot of patients after their televisit was completed, so within 1 to 3 weeks of their visit, they received a phone call from one of our research assistants. They were offered to participate in a voluntary telephone survey about their experiences, and a lot of the patients that we reached by phone were very eager to participate and share their feedback. At the time, it seemed like a whole "We're in this together" approach, both from the physician as well as the patient, trying to navigate this new form of health care delivery. We've found that the vast majority of our patients reported being very satisfied with their visit—85%. Ninety-one percent felt very comfortable sharing sensitive information with the health care provider via the telehealth platform. A lot of what we deal with in urology can be considered sensitive information, and most of our patients had no problem communicating that via a phone call or a video visit. Interestingly, 80% of them said that they would preferentially choose having a telehealth visit instead of an in-person visit in the future, if they were offered 1 vs the other. I wasn't expecting that to be quite so high. I thought that was really interesting. Some of the statistics that made a lot of sense involved the patients who had transportation issues getting to and from the office.; they had a higher rate of satisfaction. I was a little surprised that age and insurance status had no association with whether people were satisfied or not. In this era, I assumed that we would find younger patients were more inclined to use or be more adept at using this form of health care delivery. But in our study, there was no difference. All ages alike were equally satisfied.
There are a couple of things. The first and foremost is that although we all acknowledge that telehealth was a very necessary and tremendous asset during the height of the pandemic in 2020, I really think that results like these support the continued utilization of this form of health care delivery, as well as the continued push for insurance-based reimbursement for telehealth visits. So, if we had 85% of our patients saying that they were satisfied and 80% saying that they would prefer this type of visit over a face-to-face visit in the future, it's not just a form of health care delivery for emergency pandemic situations. This is something that is here to stay. We have to figure out amongst ourselves, in our community and within each individual practice, how it makes sense to integrate this going forward. In traditional literature, or prior studies about this, a lot of telehealth has been used to help bring medicine or health care to more remote areas. People have a hard time coming in person to get their health care, but it doesn't have to be the only use for this. It can be in place of a simple follow-up. Why do we have to bring a patient into the office to get a 5-minute lab test result when we could see them quickly on a video visit or phone call? It saves them a lot of time and money, and it saves the providers the hassle of having that clog the practice. It's an eye-opening experience, not just in health care overall, but how we are delivering health care to our patients.
With anything you read, any study you read, any news headline you read, you always have to take it with a grain of salt and think about the context from which that information is coming to you. The results from this study were obviously obtained during the pandemic—not during the height of the pandemic, but shortly thereafter. So, at this time our practice had shifted a little bit more to face-to-face in addition to telemedicine. Both types of visits were happening, but it was still occurring within the context of the ongoing pandemic. That very well may have influenced some of the patients' responses or their satisfaction with a telehealth visit, but taking that into account, we still, even nowadays, find that a lot of our patients will say when they see us in the office, "Hey, for my follow-up, can we just do a televisit?" The context for this has to be molded in your mind going forward. The other thing to think about in terms of interpreting our findings is that we do practice in a neighborhood that is similar to other neighborhoods and communities across the US, but is not necessarily representative of the average population of patients across the US. I have published other literature out about this particular point, in that a lot of our patients don't have very good access to broadband Internet access, or Wi Fi, or 4G, or smart devices. So, it makes it difficult for them to engage or jump on to a video visit. Having a phone visit as an alternative has been tremendous for us and it still is in our practice. How we use this within our practice may not apply universally to every other practice, especially when you look at insurance reimbursement, but these are the pieces to think about.
It's been a changing landscape since this first launched almost a year and a half ago. It's incredible to me that it's already been that amount of time because it feels like it's gone like [snaps fingers] this. During the pandemic, we literally transitioned overnight to essentially 98% telehealth, and we only had about 2% face-to-face visits for emergency and urgent patients. Over time, we've now transitioned and currently have probably about 5% to 10% of our practices as telehealth. Everybody in our department participates in some quantity of telehealth within their regular scheduled practice. The way it mixes into their day, or full days, or half days, is provider and practice-specific, but everybody unanimously has this incorporated into their practice. What we struggle with is getting our patients to adapt to the video visit concept as opposed to the phone visit. So, we are still offering both and still finding that most of our patients prefer phone visits over video visits.
The benefits are similar to what other people have reported. It obviously saves patients time and money for having to travel into the office. A lot of our patients have to take a taxi or an Uber to get here. We're not super accessible by public transportation and they avoid the wait time in the waiting room or the office exam room. I do think it can be a quicker way for us to relay information to patients. Let's say, for example, I get a result for a patient. Rather than scheduling them to come into the office to see me, I could just give them a call that day and technically bill it as a phone call telehealth visit if I'm giving them advice or clinical interpretation based on the finding. I have some colleagues in private practice who will say to me, "If I have a phone call with a patient that lasts more than 3 minutes, or I think it's going to be more than 3 minutes, I say 'I'm not doing this,' and they have to come into the office to see me." The way I look at that—it's probably also because I'm in academic medicine, not private practice—is if I can just make a 5-minute or a 10-minute phone call to them and save them that whole trip, why wouldn't I do that? The drawback for that is, do we as physicians get compensated time? Obviously in private practice, or in certain settings, there's more incentive to bring the patient in and be able to bill for an office visit. So, there is definitely some need on the part of our congressional pushes to continue reimbursement adequately for both telephone and video visits.
I do think in terms of drawbacks, as well, that this is a different mold of visits compared to an office visit. Any practice's visit schedulers need to be trained on how to talk to patients about getting them scheduled for their televisit. It's not just, "You know where Dr Watts' office is. You're going to come in Tuesday at 2:15. That's your time." That's a very easy type of appointment to schedule. But to schedule someone for a televisit, especially if they've never done it before, they have to go through a scripted template to help educate the patient on what that means, how to access it, how to troubleshoot it, how to help if they’re having trouble connecting, what the alternative is, and mention that if you can't connect, then the doctor will give you a phone call. There's a bit of an up-front investment. I think it's worth it, but if you don't do that well, then it will probably be a failing program. From a logistical and programmatic standpoint, that is a challenge, and from the visit standpoint itself, obviously a physical exam can be limited. It depends on if you're just looking at something with your eyes vs if you really need to physically examine something. Where that can be teased out is if a provider or practice hones their telehealth program to specific conditions or specific types of visits that they have agreed upon and understand are better suited for a televisit and may not require as much of an in-depth physical exam.
1. Allen AZ, Zhu D, Shin S, et al. Patient satisfaction with telephone versus video- televisits: a cross-sectional survey of an urban, multiethnic population. Urology. Published online July 29, 2021. doi:10.1016/j.urology.2021.05.096