Abstract
Introduction:
With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future.
Methods:
Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression.
Results:
One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were “inability to complete the physical examination,” “patients lack of access to technology,” and “patients lack of familiarity with the technology.”
Discussion:
Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.
Keywords: COVID-19, telemedicine, digital divide, Physical Medicine and Rehabilitation
Introduction
According to the World Health Organization, as of January 14, 2022, coronavirus disease 2019 (COVID-19) has led to more than 318 million infections and more than 5.5 million deaths.1 As social distancing measures became the norm, non-frontline specialties adapted to use telemedicine to provide routine but needed care while minimizing exposure to COVID-19. This increase in telemedicine use has been large and swift. In one study, their institution's percentage of telemedicine visits went from less than 1% of outpatient visits to more than 70% of outpatient visits in a 4-week period.2 This is consistent with another study, which found that their institution's telemedicine use grew to 62% of visits.3
Before the pandemic, Physical Medicine and Rehabilitation (PM&R) began to implement telemedicine across its subspecialties. Its use was reported in those with spinal cord injury (SCI),4–7 brain injury,8–11 and stroke.12–14 In addition, it was beginning to emerge for musculoskeletal medicine as well.15–18 For SCIs and brain injuries, the Veterans Health Administration was using telemedicine to connect subspecialists with Veterans at remote sites.7,9 In addition, programs using iPads to deliver care to individuals with SCI were shown to be well received by patients,4,5 and telerehabilitation for shoulder pain has been shown to be effective in reducing pain and improving function.6 In the brain injury population, telemedicine to implement cognitive testing has been shown to be feasible8 and video visits have been demonstrated to be of equivalent cost to in-person evaluations.10 In the pediatric population, telepsychology was found to have both advantages and disadvantages.11 In stroke, telerehabilitation was shown to be feasible,12 effective in the treatment of aphasia13 and to improve function.14 In the musculoskeletal population, telemedicine was shown to allow for equivalent diagnostic results to in-person evaluations,15 as well as to provide comparable treatment,16 with decreased wait times and cost.17,18
With the COVID-19 pandemic, additional research is being presented to support the implementation of telemedicine. Verduzco-Gutierrez et al. published a guide to completing an outpatient physiatry telemedicine visit.19 Likewise, early work by Tenforde et al. during the pandemic showed that telemedicine visits from both patients and physicians were well received.20 This growth of telemedicine not only may be helpful to continue social distancing measures in the setting of the pandemic but also may create new opportunities to care for our patients in the post-pandemic world.
While telemedicine has been shown to adequately deliver care, there still remain barriers to expansion. The digital divide refers to the varied experience that different groups have with access to technology. For example, while the 2018 census data indicate that 85% of households had broadband internet, when examined by age, race, and income level, disparities became apparent.21 Additionally, there is evidence that the digital divide exists among those with disabilities as well.22,23
In this study, we surveyed physiatrists about their use of telemedicine before and during the pandemic as well as their anticipated use following the pandemic. We also explore the potential barriers to use of telemedicine with hope to understand how to overcome them in the future.
Methods
The study was determined to be exempt by the University of California Irvine Institutional Review Board exempt self-determination tool.
An initial set of questions was designed based on the Sittig and Singh's framework for understanding health information technology in a health care setting.24 This design was also influenced by Martinez et al.'s two publications focused on the implementation of telemedicine programs in brain injury9 and SCI,7 which also used Sittig and Singh's framework. The initial questions were honed through review by the research team to be clear, direct, and inclusive. After review, the questions were entered into a Google form and was piloted by the research team to ensure that the format was simple to use and functioned as intended.
The survey was designed with 22 questions broken into 4 sections, which allowed for sections to be skipped by respondents when their answer choices indicated that the subsequent sections would not be relevant. The questions explored the demographics of the respondents, the percentage of a respondent's practice conducted via telemedicine before and during the pandemic while a third question inquired about how much they anticipated continuing to use telemedicine after the pandemic. Other questions explored the platforms used, training received, characteristics of in-person versus virtual encounters, and barriers to the use of telemedicine. Free response questions were optional, whereas all other questions were mandatory. (Complete survey is available as part of Supplementary Data S1)
The survey was distributed among multiple PM&R departments and residency programs via email. It was also posted on various social media outlets including Facebook groups dedicated to PM&R physicians and Twitter. The survey was available from June 2, 2020, to August 1, 2020.
All data were analyzed with R (version 3.6.2). Demographic and clinical characteristics were categorical, and they are summarized using frequency and percentages. The primary outcomes were telemedicine use before the pandemic, during the pandemic, and after the pandemic, length of telemedicine visits, as well as training sufficiency. Univariate logistic regression models were used to investigate the associations between the outcomes and each categorical characteristic. A univariate analysis was chosen as the goal of the project was to describe telemedicine use among physiatrists and assess overall trends in the data, rather than to try to determine more rigorous cause and effect among variables. Participants could select multiple subspecialties and practice settings, and separate regression models were fitted for each of these categories. The odds ratios (ORs), 95% confidence intervals (CIs), and p-values were derived from these models.
Results
A total of 171 participants completed the survey, including 137 (80.1%) attending physicians and 34 (19.9%) residents and fellows. The majority of respondents were women (73.1%), and the largest age group represented was physicians aged 31–40 years (55.6%). The majority of respondents spent time either in academic practice (35.1%) or in private practice (32.2%). 41.5% of respondents had some component of general physiatry in their practice, 20.5% had some component of pain, 17.5% brain injury, 16.4% sports medicine, and 12.9% SCI. Demographics of the survey respondents are listed in Table 1. Descriptive data of the responses to the survey are presented in Table 2. All significant associations from univariate logistic analysis are provided in Table 3. Supplementary Data S2 contain all univariate logistic analysis of anticipated telemedicine use after the pandemic.
Table 1.
Baseline Demographics of 171 Physiatrists Surveyed from June 2, 2020, to August 1, 2020, About Their Use of Telemedicine Before, During, and Anticipated After the COVID-19 Pandemic
| SUBJECT CHARACTERISTIC (N = 171) | % (n) |
|---|---|
| Age, years (N = 171) | |
| 20–30 | 8.8 (15) |
| 31–40 | 55.6 (95) |
| 41–50 | 26.9 (46) |
| 51+ | 8.8 (15) |
| Gender (N = 171) | |
| W:M | 125:46 |
| Level of training (N = 171) | |
| Attending | 80.1 (137) |
| Resident/fellow | 19.9 (34) |
| Specialtya (all that apply) | |
| General physiatry | 41.5 (71) |
| Pain | 20.5 (35) |
| Sports medicine | 16.4 (28) |
| Brain injury | 17.5 (30) |
| Spinal cord injury | 12.9 (22) |
| Neuromuscular medicine | 8.8 (15) |
| Pediatric | 9.4 (16) |
| Palliative | 1.2 (2) |
| Still training | 14.0 (24) |
| Otherb | 9.9 (17) |
| Practice settinga (all that apply) | |
| Private practice | 32.2 (55) |
| Academic | 35.1 (60) |
| Still in training | 16.4 (28) |
| Military or VA | 5.3 (9) |
| Multiple | 4.7 (8) |
| Otherc | 6.4 (11) |
| Practice breakdowna (N = 171) | |
| Mostly outpatient | 48.0 (82) |
| Mostly inpatient | 17.0 (29) |
| Equal inpatient and outpatient | 18.7 (32) |
| Unknown | 16.4 (28) |
Specialty, practice setting, and practice breakdown were asked of attending physicians only.
Other specialty: spasticity, palliative, women's health, and occupational medicine respondents.
Other setting: Skilled Nursing Facility, Locum tenens, Community Health Center, Kaiser Permanente.
VA, Veterans Affairs; W, women; M, men.
Table 2.
Breakdown of Responses from 171 Physiatrists Surveyed from June 2, 2020 to August 1, 2020 About Their Use of Telemedicine Prior to, During, and Anticipated After the COVID-19 Pandemic
| % (n) | |
|---|---|
| What percentage of your practice was telemedicine before the COVID pandemic? (N = 171) | |
| Did not use telemedicine | 82.5 (141) |
| 1–25% of practice | 15.8 (27) |
| 26–50% of practice | 0.6 (1) |
| 51–75% of practice | 1.2 (2) |
| 76–99% of practice | 0 (0) |
| 100% of practice | 0 (0) |
| What percentage of your practice is currently telemedicine? (N = 171) | |
| Have not used telemedicine during pandemic | 9.4 (16) |
| 1–25% of practice | 33.3 (57) |
| 26–50% of practice | 18.7 (32) |
| 51–75% of practice | 17.5 (30) |
| 75–99% of practice | 12.3 (21) |
| 100% of practice | 8.8 (15) |
| Did you receive training in telemedicine? (N = 155) | |
| Yes | 34.8 (54) |
| No, and I wish I had | 33.5 (52) |
| No, and I do not think it was necessary | 31.6 (49) |
| Was the training to provide telemedicine sufficient? (N = 54) | |
| It was helpful and I did not need to learn anything on my own | 18.5 (10) |
| It was helpful, but I needed to learn a few things on my own | 70.4 (38) |
| It was helpful, but I needed to learn a large number of things on my own | 11.1 (6) |
| It was not helpful, I had to learn everything on my own | 0 (0) |
| What is your preferred platform of telemedicine? (N = 155) | |
| Secure hospital provided platform | 65.8 (102) |
| My own secure platform | 17.4 (27) |
| A non-secure platform | 4.5 (7) |
| Phone visit | 5.8 (9) |
| Othera | 6.5 (10) |
| Do you feel comfortable using non-secure methods of telemedicine such as FaceTime and Skype that have been approved for use during the COVID pandemic? (N = 155) | |
| Yes | 40.0 (62) |
| No | 60.0 (93) |
| Compared with an in-person encounter, how well does telemedicine allow you to accomplish the goals of each type of visit? (N = 155) | |
| New patient visit | |
| Easier than in-person | 3.2 (5) |
| The same as in-person | 3.9 (6) |
| More difficult than in-person | 92.9 (144) |
| Routine follow-up | |
| Easier than in-person | 41.3 (64) |
| The same as in-person | 36.1 (56) |
| More difficult than in-person | 22.6 (35) |
| Follow-up with new chief complaint | |
| Easier than in-person | 5.2 (8) |
| The same as in-person | 20.2 (31) |
| More difficult than in-person | 74.8 (116) |
| COVID-19 screen | |
| Easier than in-person | 53.5 (83) |
| The same as in-person | 36.1 (56) |
| More difficult than in-person | 10.3 (16) |
| Opioid medication refill | |
| Easier than in-person | 31.0 (48) |
| The same as in-person | 54.8 (85) |
| More difficult than in-person | 14.2 (22) |
| Non-opioid medication refill | |
| Easier than in-person | 46.5 (72) |
| The same as in-person | 49.7 (77) |
| More difficult than in-person | 3.9 (6) |
| Will you continue to use telemedicine after the pandemic? (N = 155) | |
| Yes, the same amount as before the pandemic | 4.5 (7) |
| Yes, more frequently than before the pandemic | 59.4 (92) |
| Yes, but less frequently than before the pandemic | 27.1 (42) |
| No, I will no longer use telemedicine after the pandemic | 9.0 (14) |
| What was the length of your typical new patient visit using telemedicine? (N = 155) | |
| <20 minutes | 12.3 (19) |
| 20–30 minutes | 33.5 (52) |
| 30–45 minutes | 31.0 (48) |
| 45–60 minutes | 21.9 (34) |
| >60 minutes | 1.3 (2) |
| What was the length of your typical follow-up visit using telemedicine? (N = 155) | |
| <15 minutes | 32.3 (50) |
| 15–25 minutes | 47.7 (74) |
| 25–40 minutes | 16.8 (26) |
| >40 minutes | 3.2 (5) |
| On average, are your telemedicine visits longer or shorter than your typical office visits? (N = 155) | |
| Shorter | 53.5 (83) |
| Same length | 27.1 (42) |
| Longer | 19.4 (30) |
Other telemedicine platform included: doximity, zoom, and large secure platform.
Table 3.
Univariate Logistic Regression Analysis Significant and Relevant Nonsignificant Associations from Survey of 171 Physiatrists Conducted from June 2, 2020, to August 1, 2020, About Their Use of Telemedicine Before, During, and Anticipated After the COVID-19 Pandemic
| OR (95% CI) | p | |
|---|---|---|
| Telemedicine use before pandemic (N = total number who answered question, n = number who used telemedicine before pandemic) | ||
| Subspecialty—other (reference is all other subspecialties) (N = 171, n = 30) | 3.99 (1.33–11.5) | 0.015 |
| Practice setting—academic (N = 171, n = 30) | Ref. | <0.001 |
| Practice setting—private practice (N = 171, n = 30) | 3.50 (1.11–13.3) | |
| Practice setting—still in training (N = 171, n = 30) | 2.33 (0.51–10.6) | |
| Practice setting—military or VA (N = 171, n = 30) | 49.0 (8.81–420) | |
| Practice setting—multiple (N = 171, n = 30) | 8.40 (1.36–50.6) | |
| Practice setting—other (N = 171, n = 30) | 1.40 (0.07–10.8) | |
| Practice type—inpatient (N = 143, n = 26) | Ref | 0.009 |
| Practice type—inpatient/outpatient (N = 143, n = 26) | 4.00 (0.55–80.9) | |
| Practice type—outpatient (N = 143, n = 26) | 9.64 (1.87–177) | |
| Current use of telemedicine (N = total number who answered question, n = number who used currently) | ||
| Subspecialty—general (reference is all other subspecialties) (N = 171, n = 98) | 0.47 (0.25–0.87) | 0.016 |
| Subspecialty—pediatrics (reference is all other subspecialties) (N = 171, n = 98) | 5.92 (1.58–38.5) | 0.006 |
| Practice type—inpatient (N = 143, n = 83) | Ref | <0.001 |
| Practice type—inpatient/outpatient (N = 143, n = 83) | 3.56 (1.22–11.2) | |
| Practice type—outpatient (N = 143, n = 83) | 8.06 (3.16–22.8) | |
| Use of telemedicine before pandemic (reference is those who did not use telemedicine before the pandemic) (N = 171, n = 98) | 8.87 (2.96–38.3) | <0.001 |
| Anticipated future use of telemedicine (N = total number who answered question, n = number who anticipated use after the pandemic) | ||
| Subspecialty—spinal cord injury (reference is all other subspecialties) (N = 155, n = 99) | 0.31 (0.11–0.84) | 0.022 |
| Gender—women (N = 155, n = 99) | 0.40 (0.17–0.89) | 0.024 |
| Practice setting—academic (N = 155, n = 99) | Ref | <0.16 |
| Practice setting—private practice (N = 155, n = 99) | 0.42 (0.19–0.93) | |
| Practice setting—still in training (N = 155, n = 99) | 1.24 (0.44–3.91) | |
| Practice setting—military or VA (N = 155, n = 99) | 1.54 (0.33–11.0) | |
| Practice setting—multiple (N = 155, n = 99) | 0.44 (0.09–2.04) | |
| Practice setting—other (N = 155, n = 99) | 1.17 (0.30–5.81) | |
| Practice type—inpatient (N = 132, n = 82) | Ref | 0.010 |
| Practice type—inpatient/outpatient (N = 132, n = 82) | 5.50 (1.69–19.7) | |
| Practice type—outpatient (N = 132, n = 82) | 3.79 (1.41–11.0) | |
| Used telemedicine before pandemic (reference is those who did not use telemedicine before the pandemic) (N = 155, n = 99) | 6.62 (2.19–28.8) | <0.001 |
| Using telemedicine currently (reference is those who did not currently use telemedicine) (N = 155, n = 99) | 2.41 (1.23–4.80) | 0.011 |
| Received training (N = 155, n = 99) | Ref | 0.017 |
| Did not receive training and wish they had (N = 155, n = 99) | 0.60 (0.25–1.39) | |
| Did not receive training and did not think it was necessary (N = 155, n = 99) | 0.30 (0.13–0.69) | |
| Training insufficient (N = 155, n = 99) | Ref | 0.003 |
| Training sufficient (N = 155, n = 99) | 0.36 (0.18–0.71) | |
| Preferred platform—secure hospital provided platform (N = 155, n = 99) | Ref | 0.007 |
| Preferred platform—my own secure platform (N = 155, n = 99) | 0.47 (0.20–1.15) | |
| Preferred platform—phone visit (N = 155, n = 99) | 0.11 (0.02–0.48) | |
| Preferred platform—non-secure platform (N = 155, n = 99) | 0.63 (0.14–3.24) | |
| Preferred platform—other (N = 155, n = 99) | 0.19 (0.04–0.77) | |
| Shorter/same length of telemedicine visit (N = total number who answered question, n = number who reported telemedicine visits were shorter or same length as telemedicine visits) | ||
| Subspecialty—other (N = 155, n = 125) | 0.19 (0.06–0.56) | 0.003 |
| Received training (N = 155, n = 125) | Ref | 0.039 |
| Did not receive training and wish they had (N = 155, n = 125) | 2.01 (0.81–5.25) | |
| Did not receive training and did not think it was necessary (N = 155, n = 125) | 3.71 (1.31–12.2) | |
| Longer length of telemedicine visit (N = total number who answered question, n = number who reported telemedicine visits were longer length compared to telemedicine visits) | ||
| Subspecialty—other (reference is all other subspecialties) (N = 155, n = 30) | 5.32 (1.78–16.0) | 0.003 |
| Received training (N = 155, n = 30) | Ref | 0.039 |
| Did not receive training and wish they had (N = 155, n = 30) | 0.50 (0.19–1.23) | |
| Did not receive training and did not think it was Necessary (N = 155, n = 30) | 0.27 (0.08–0.76) | |
| Sufficient training in telemedicine (N = total number who answered question, n = number who reported telemedicine training was sufficient) | ||
| Subspecialty—sports medicine (reference is all other subspecialties) (N = 155, n = 59) | 2.39 (1.03–5.63) | 0.042 |
| Still in training (reference is those no longer in training) (N = 155, n = 59) | 0.25 (0.06–0.78) | 0.016 |
| Practice setting—academic (N = 155, n = 59) | Ref | 0.037 |
| Practice setting—private practice (N = 155, n = 59) | 2.41 (1.09–5.43) | |
| Practice setting—still in training (N = 155, n = 59) | 0.44 (0.12–1.38) | |
| Practice setting—military or VA (N = 155, n = 59) | 2.63 (0.63–11.7) | |
| Practice setting—multiple (N = 155, n = 59) | 0.70 (0.10–3.38) | |
| Practice setting—other (N = 155, n = 59) | 1.75 (0.45–6.56) | |
| Will continue to use telemedicine after the pandemic (reference is those who will not continue to use telemedicine after the pandemic) (N = 155, n = 59) | 0.36 (0.18–0.71) | 0.003 |
| Insufficient training in telemedicine (N = total number who answered question, n = number who reported telemedicine training was insufficient) | ||
| Subspecialty—sports medicine (reference is all other subspecialties) (N = 155, n = 96) | 0.42 (0.18–0.97) | 0.042 |
| Subspecialty—still in training (reference is all other subspecialties) (N = 155, n = 96) | 4.02 (1.27–17.8) | 0.016 |
| Practice setting—academic (N = 155, n = 96) | Ref | 0.037 |
| Practice setting—private practice (N = 155, n = 96) | 0.42 (0.18–0.92) | |
| Practice setting—still in training (N = 155, n = 96) | 2.26 (0.73–8.60) | |
| Practice setting—military of VA (N = 155, n = 96) | 0.38 (0.09–1.59) | |
| Practice setting—multiple (N = 155, n = 96) | 1.42 (0.30–10.3) | |
| Practice setting—other (N = 155, n = 96) | 0.57 (0.15–2.20) | |
| Will continue to use telemedicine after the pandemic (reference is those who will not continue to use telemedicine after the pandemic) (N = 155, n = 96) | 2.79 (1.42–5.55) | 0.003 |
CI, confidence interval; OR, odds ratio.
Before the pandemic, only 17.5% of respondents used telemedicine and the majority of those used it for 1–25% of their practice. Practice setting was considered a statistically significant factor associated with telemedicine use before the COVID-19 pandemic. Those practicing in the military or Veterans Affairs (VA) setting (OR, 49.0, 95% CI, 8.81–420) were most likely to have had used telemedicine before the pandemic compared with those in the academic setting. Additionally, those in private practice (OR, 3.50, 95% CI, 1.11–13.3), or multiple practice settings (OR, 8.40, 95% CI, 1.36–50.6), were more likely to use telemedicine before the pandemic compared with those practicing in the academic setting. Additionally, physiatrists who practiced mostly outpatient medicine (OR, 9.64, 95% CI, 1.87–177) were more likely to use telemedicine compared with those who practiced mostly inpatient.
At the time of the survey, 73 (42.7%) respondents reported utilizing telemedicine for 1–25% of their practice or not at all, 62 (36.3%) respondents were using it for 26–75% of their practice, and 36 (21.1%) were using it for 76–100% of their practice. Factors associated with the current use of telemedicine include pediatric rehabilitation (OR, 5.92, 95% CI, 1.58–38.5) and telemedicine use before the pandemic (OR, 8.87, 95% CI, 2.96–38.3). Those who practice general physiatry were considered less likely to use telemedicine (OR, 0.47, 95% CI, 0.25–0.87). Those who practiced mostly outpatient (OR, 8.06, 95% CI, 3.16–22.8) or equally inpatient and outpatient (OR, 3.56, 95% CI, 1.22–11.2) were more likely to use telemedicine compared with those who practiced mostly inpatient.
Looking at telemedicine use after the pandemic, of the 155 respondents who were using telemedicine at the time of the survey, 99 (63.9%) said that they would use telemedicine the same amount or more than before the pandemic. Women compared with men (OR, 0.40, 95% CI, 0.17–0.89) and those who identified part of their practice as SCI medicine compared with all other subspecialties (OR, 0.31, 95% CI, 0.11–0.84) were significantly associated with reduced likelihood of using telemedicine after the pandemic. Again, those who practiced equally outpatient and inpatient (OR, 5.50, 95% CI, 1.69–19.7) or mostly outpatient (OR, 3.79, 95% CI, 1.41–11.0) were more likely to use telemedicine after the pandemic compared with those who practiced mostly inpatient.
Those who did not have training in telemedicine and thought it was unnecessary (OR, 0.30, 95% CI, 0.13–0.69) were less likely to use telemedicine after the pandemic compared with those who received training. Those who felt that the training they did receive was sufficient (OR, 0.36, 95% CI, 0.18–0.71) were less likely to use telemedicine after the pandemic compared with those who felt that their training was insufficient. Physicians who conducted a phone visit (OR, 0.11, 95% CI, 0.02–0.48), or used other platforms (OR, 0.19, 95% CI, 0.04–0.77) were less likely to use telemedicine in the future compared with those who had a preferred hospital provided platform.
However, those who currently used telemedicine compared with those who did not (OR, 2.41, 95% CI, 1.23–4.80) and those who used telemedicine before the pandemic compared with those who did not (OR, 6.62, 95% CI, 2.19–28.8) were likely to continue using telemedicine after the pandemic. Finally, while practice setting was considered a statistically significant predictor of use of telemedicine before the pandemic, it was not a predictor of use after the pandemic.
In regard to visit length when considering a typical telemedicine visit, 125 of 155 respondents who reported that they currently use telemedicine (80.6%) said their telemedicine visits were the same length or shorter than in-person visits. Physiatrists who did not receive training in telemedicine and did not think it was necessary (OR, 3.71, 95% CI, 1.31–12.2) were more likely to report telemedicine visits of the same length or shorter compared with those who received training for telemedicine.
Sufficiency of telemedicine training was broken down into those who were not trained or those who were and deemed their training insufficient and those who did receive training and felt that there was little more to learn. Sport medicine physicians (OR, 2.39, 95% CI, 1.03–5.63) were more likely to feel that they had sufficient training in telemedicine compared with those who were not sports medicine physicians. Those in private practice (OR, 2.41, 95% CI, 1.09–5.43) were more likely to be trained and feel that training was sufficient compared with those practicing in the academic setting. However, physicians who were still in training such as residents and fellows (OR, 4.02, 95% CI, 1.27–17.8) compared with all other subspecialties were more likely to report no or insufficient training in telemedicine.
Additionally, we also asked those surveyed what their first, second, and third biggest barriers were to using telemedicine. The complete results are provided in Table 4. The three most popular responses when adding up the first, second, and third biggest barriers were “inability to complete the physical examination,” “patients lack of access to technology,” and “patients lack of familiarity with the technology.” The least common barriers to use telemedicine include “providers lack of familiarity with technology,” “providers lack of access to technology or internet,” “scheduling,” and “difficulty coding.”
Table 4.
Top Three Barriers to the Use of Telemedicine Identified By Survey of Physiatrists Conducted from June 2, 2020, to August 1, 2020, About Their Use of Telemedicine Before, During, and Anticipated After the COVID-19 Pandemic (Multiple Responses Per Person)
| FIRST BIGGEST BARRIER | SECOND BIGGEST BARRIER | THIRD BIGGEST BARRIER | TOTAL | |
|---|---|---|---|---|
| Inability to complete the physical examination | 84 | 30 | 14 | 128 |
| Patients lack of access to technology | 15 | 27 | 29 | 71 |
| Patients lack of familiarity with the technology | 13 | 29 | 25 | 67 |
| Difficulty collecting reimbursement | 27 | 15 | 13 | 55 |
| Telemedicine can be difficult to use for people with disabilities because of their functional limitations | 5 | 9 | 18 | 32 |
| Difficulty in establishing a relationship with the patient | 2 | 17 | 9 | 28 |
| Lack of support staff in the clinic | 1 | 11 | 14 | 26 |
| Telemedicine adds more work/takes more time than in-person visits | 3 | 2 | 14 | 19 |
| Lack of providers institutional support | 4 | 3 | 3 | 10 |
| Difficulty coding | 1 | 4 | 3 | 8 |
| Scheduling | 0 | 3 | 5 | 8 |
| Providers lack of access to technology or internet | 0 | 3 | 3 | 6 |
| Providers lack of familiarity with technology | 0 | 0 | 1 | 1 |
| Total | 155 | 153 | 151 |
Discussion
Overall, only 17.5% of physicians reported using telemedicine before the pandemic; however, for the vast majority of people, it only represented 1–25% of their practice before the pandemic, both of which are consistent with other studies.2,25 Interestingly, when asked about the use after the pandemic, 63.9% of respondents said that they would use telemedicine the same amount or more than before the pandemic.
While our results show increased use during the pandemic, barriers noted were “inability to complete the physical examination,” “patients lack of access to technology,” and “patients lack of familiarity with the technology.” Many of these concerns were consistent with a study of telerehabilitation use by physical therapists, occupational therapists, and other allied health professionals as well as telemedicine being implemented by rehabilitation physicians. This article discussed potential barriers, which included cost, an absence of protocols, reimbursement, technical challenges, security concerns, patient satisfaction, physician perception, and medical/legal concerns.26
Despite these barriers, our data suggest that there will be an increase in telemedicine use following the pandemic as familiarity among providers and patients has grown. In addition, publications are addressing the risks of care via telemedicine and how to urgently and systematically address infrastructure and access barriers.27
The second two most popular barriers noted that both allude to the more difficult to address issue of the digital divide. In our survey, 32 respondents listed functional limitations of our patient population as a potential barrier to use telemedicine. Approaches to overcome the digital divide include providing patients with tablets,5,28 adaptive devices such as trackball mice, head-mounted technology, and voice recognition technology29,30 or bringing them to a local clinic to have a teleconsultation with a specialist.7,9 These suggested modifications would increase convenience for patients with functional limitations.
Military and VA physiatrists had the highest OR to use telemedicine before the pandemic. At first, it was thought that this was related to billing as a barrier; however, difficulty with reimbursement was not among the top three most common barriers listed. The ease with which military and VA physiatrists are able to use telemedicine may have to do with their institutions’ work to reduce the digital divide. In fact, two VA programs, the Care Coordination Home Telehealth Program and the My HealtheVet Personal Health Record Portal, have been described to build recommendations for other organizations.31
In fact, while only 10 people listed institutional support as a barrier, several examples of institutional support were associated with increased telemedicine use. Those who had a preferred hospital-provided platform were more likely to continue to use telemedicine after the pandemic, which is consistent with the finding that those who were using telephone as their main method of communication were least likely to use telemedicine after the pandemic compared with those with a secure hospital-provided platform. As far as training, those who did not have training in telemedicine and thought it was unnecessary were less likely to use telemedicine after the pandemic compared with those who had training.
Those who felt that the training they did receive was sufficient were less likely to use telemedicine after the pandemic compared with those who felt that their training was insufficient. One interpretation of these responses is that those who felt that their training was not necessary or was sufficient did not feel that telemedicine training was needed because they did not intend to use telemedicine after the pandemic rather than feel that it was not needed because telemedicine use was intuitive.
SCI physiatrists had the lowest OR to continue to use telemedicine after the pandemic. This could be for a variety of reasons, including feeling that physical examination is limited on video and that a comprehensive physical examination is needed for such patients, that the functional deficits caused by a SCI could limit participation in virtual care, or perhaps procedures such as botulinum toxin injections cannot be done virtually. In contrast, studies conducted in other neurorehabilitation populations have shown telemedicine to be cost-effective,10 feasible,12 and effective.13,14
Overall, telemedicine has been well received by both patients and providers during this pandemic. A recent study conducted during the early phase of the pandemic looking at physician and patient satisfaction via online survey in a single early adopter PM&R department found that a majority of physicians and patients felt that the experience in their outpatient sports medicine practices was positive. These findings give hope that expansion of telemedical services across the spectrum of rehabilitation care will continue.20
LIMITATIONS
Limitations of our study include that our survey was posted online, which attracted participants who were younger or likely more familiar with technology that can translate into familiarity with telemedicine use. Our survey was also conducted relatively early in the pandemic when it was unknown how long the pandemic would last. In addition, our sample size appears small, but this is consistent with other surveys of providers and patients during the pandemic32–35 and is offset by the diversity of practice subspecialties and settings represented. In addition, physiatry is also a small specialty. According to the American Medical Association in 2019, there were 9,767 physiatrists in the United States compared with 120,171 Internal Medicine physicians (the largest specialty) and 938,980 total physicians.36 We were also not able to calculate a response rate given how we recruited for participants; this is a common limitation among other online survey projects.37–39
Conclusions
Overall, our results show increased telemedicine use during the pandemic, and physicians' preference to continue to use telemedicine following the pandemic in particular among those whose institutions supply a secure platform. While barriers continue to exist for broader implementation of telemedicine, focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.
Supplementary Material
Disclosure Statement
No competing financial interests exist.
Funding Information
Supplementary Material
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