Barriers and challenges to telemedicine usage among the elderly population in Israel in light of the COVID-19 era: A qualitative study

Abstract

Background

Although there may still be many challenges to its adoption, telemedicine is becoming more and more popular for helping elderly people preserve their independence and continue to live in their own homes. We intended to investigate the challenges and barriers (if any) experienced by the elderly population when using telemedicine services in Israel.

Methods

Fourteen elderly people were recruited for the study and interviewed in person using a semistructured interview protocol, using a qualitative technique. Participants’ replies were evaluated and analyzed thematically. The participants were questioned regarding their usage of telehealth services, the benefits they perceive in them, any potential difficulties or hurdles to use, and suggestions they had for making these services more readily available and simpler to use for the elderly.

Results

Most participants recognized the advantages of telehealth services, particularly for the elderly population during pandemics and normal times. However, most of them also expressed various challenges that face the elderly population in using these services. Many participants were concerned that the quality of telemedicine sessions may not be good enough compared to in-person sessions, and expressed a lack of confidence in telemedicine services, and frustration from the absence of in-person interaction and communication. Many participants highlighted the technological challenges in the use of computers and applications in general and in the context of healthcare, in particular, in addition to physiological and literacy difficulties. Finally, the participants suggested several ways to increase the accessibility and usage of telemedicine solutions by elderly people.

Conclusions

A proactive approach to identifying and resolving telehealth barriers can maximize virtual interactions for the older population and alleviate care inequities. In addition to identifying barriers that impede older patients from using telemedicine, there is a need to increase awareness of the availability, benefits, and uses of each telehealth service in comparison to in-person consultations.

Introduction

Telemedicine is the most modern form of medical service delivery and is used in situations where the physician and patient are not in the same location. ¹

Telemedicine includes numerous technical devices and tools as well as professional health services to support, monitor, and care for people remotely. Users can maintain their autonomy and improve their quality of life through a variety of services, including communication, counseling, monitoring, diagnostics, and education. ²

In the wake of the 2019 coronavirus pandemic (COVID-19), in which many countries have begun to integrate remote medicine technologies into their healthcare services, and to protect healthcare workers and patients, there has been a massive shift to telemedicine by promoting video visits to reach patients at home. ³

A significant proportion of older adults suffer from at least one chronic disease that requires regular monitoring and self-management. ⁴

With an aging population and a greater prevalence of long-term conditions, telecare is becoming more and more popular for helping elderly persons remain independent and continue to live in their own homes. It provides a sense of safety and security to the elderly and appears to be one of the most promising approaches to enable independent living in a residential community.^2,5

However, there are a variety of barriers that older patients may face, ranging from technical issues to medical conditions to life circumstances, and these obstacles may result in a digital disadvantage for these patients.

A major component of telehealth is the use of technology to transfer information between the parties involved, which can be problematic for older people who might not have access to the necessary electronic devices and services to utilize this type of care. ⁶

Even if older persons have access to technology, issues may still develop if they lack technical expertise, are unable to resolve issues that do arise, or are unable to adjust to digital communication. Patients who participate in video visits must have the technical know-how and aptitude to connect to the internet, use, and troubleshoot audiovisual equipment, and converse without the in-person cues. Many older folks might not be able to do this due to impairments or a lack of technological skills. ²

Older adults frequently resist using new technology, especially when it comes to learning the knowledge and skills required to utilize computers and other gadgets and devices. ⁷

Furthermore, in addition to the symptoms of a chronic disease, the elderly may also face changes in their eyesight, hearing, dexterity, and even cognitive issues that might make using various telehealth devices and conversing online challenging for them.^7–9

The socioeconomic situation of older persons may also have an impact on their readiness or capacity to engage in telehealth conversations. ¹⁰

Sadly, despite the fact that many telehealth systems in use are successful and effective, these technologies are frequently created without considering how easy they would be for patients and caregivers to utilize. ¹¹

In addition to all of the aforementioned barriers, many people also believe that older people are either uninterested in using technology or are unable to use its many platforms. In fact, the majority of older people own and use a computer, smartphone, or tablet with internet connection at home, yet older people have limited access to telehealth services. ¹²

Israel is seen as a highly developed nation with solid infrastructure, high levels of innovation and entrepreneurship, and high levels of awareness of telemedicine services. The Ministry of Health (MoH) stated that its goal was to “bring about a leap in the health system that will enable it to become sustainable, advanced, innovative, renewed, and constantly improving, by optimally leveraging the information and communication technologies available to the entire Israeli population” as part of the “Digital Israel project.” ¹³

The four HMOs (Health Maintenance Organizations) in Israel provide telemedicine services with a personal doctor as well as on the weekends, evenings, and nights. Like in other affluent countries, the COVID-19 pandemic has increased the use of telemedicine in Israel.

In this qualitative study, we sought to identify the challenges and barriers (if any) faced by the senior population when utilizing telemedicine services in Israel, a nation that appears to have all the necessary resources to provide high-quality telemedicine services.

Methods

Study design

To gather detailed and accurate information that would accurately reflect the participants’ subjective experiences, we employed a semistructured qualitative study (SSQS) technique in this study. Participants’ replies were evaluated and analyzed thematically when themes were found. ¹⁴

The use of open-ended questions allowed participants to openly explain the advantages of, difficulties with, and recommendations for enhancing telehealth for the elderly, which gave the study its qualitative quality. The research complied with the Standards for Reporting Qualitative Research's (SRQR) Standards for Qualitative Research Items. ¹⁵

To make sure we followed all the guidelines of qualitative studies, we conducted a qualitative studies checklist (COREQ) (Supplemental Appendix 1).

Study type and sample size:

We employed a qualitative content analysis method.

Similar to grounded theory technique, in qualitative Content Analysis one can investigate a specific event or process and develop new hypotheses that are founded on the gathering and examination of empirical facts.

As well explained by Cho & Lee ¹⁶ —“Qualitative content analysis is frequently employed to answer questions such as what, why and how, and the common patterns in the data are searched for by using a consistent set of codes to organize text with similar content.” Qualitative content analysis focuses on extracting categories from the data.

The process of gathering and analyzing data iteratively continues until theoretical saturation is reached, which is the point at which more data are of no further use in illuminating new theory. There comes a point when the problem under examination has reached saturation and further data collection provides no further new information. There is more data, but that doesn't necessarily indicate there is more information because the same information keeps coming up again and again.

Since we conceived and carried out the study using this technique, the number of participants wasn't limited or stated.^15,16

Participants and setting

Participants were eligible if they were 65 years and older and belonged to the principal investigator's clinic.

A convenience sampling method was used in which all interested individuals who qualified and agreed to participate were eligible.

All participants belonged to the Nordau Health Center, in the city of Hadera, which belongs to Clalit health services.

This clinic is one of many community-care clinics in Israel, which belong and operated by one of the four Health funds (Health Maintenance Organizations, HMO's) in Israel. Clalit is the largest provider of public and semiprivate health services in Israel, and has over 4.5 million customers, which are 53% of market share.

In the city of Hadera, this clinic serves 6500 people and is situated in a quiet neighborhood. The clinic provides primary healthcare services to people from the surrounding neighborhoods, and includes four GPs and one pediatrician, three nurses, social worker, dietician, and pharmacy services, in addition to office services.

This clinic serves a very diverse range of people, including those who were born in Israel, as well as those who immigrated there from other nations (including Ethiopians, Russians, and many others), as well as people of all ages (since birth), genders, different socioeconomic statuses, various cultures and religions, and different denominations.

The participants were approached randomly by the first author (MH) (male, pediatrician, MD, PhD, MH) when they visited the clinic for various routine reasons (appointment with their physician, blood examinations, or just a simple administrative task). The first author, who is the primary investigator is trained (academic studies) and experienced in performing qualitative research and interviews. The Interviewer was the one initiated the study and interested in the study topics (performed many studies on telehealth and belongs to health-disparities working group at the International Society of Telemedicine and eHealth).

Since the study's population consisted of senior persons and the first author is a pediatrician, no relationship had been established before the study began.

Even though some of the participants choose to attend at a different time, everyone who was approached agreed to take part in the study.

After the first author introduced himself and purpose of the study was explained to the participants and they gave their consent to participate, they were interviewed in person (face-to-face) by the first author in a special room at the clinic. The interviews were recorded (audio) and transcribed verbatim.

Only the first author (MH, interviewer) and one participant at a time were present in the room during the interview.

Data collection

To extract the Participants’ experiences, challenges, and opinions regarding their encounter with telemedicine, a semistructured interview protocol was adopted. With this tool, we were able to direct the participants toward areas of interest while allowing them to elaborate on their responses, resulting in richer data (Qualitative content analysis method, as previously described).

The areas of interest for the study and the domains identified in the literature served as the basis for discussion topics.

The interview questions were created with input from all the authors.

The participants were questioned about their prior and current use of telehealth services (especially before and during the COVID-19 pandemic), the advantages they see in them, potential challenges and barriers to using telemedicine and digital health services, and whether the COVID-19 pandemic had any impact on their willingness or ability to use these services. They were also questioned about how they used these services after the COVID-19 pandemic ended (and whether this period had changed anything), as well as what suggestions they had for making these services more easily accessible and easier to use for the elderly.

The interview-protocol consisted of four sections, which included some close-ended questions, followed by many open-ended questions. The interview protocol is presented in Table 1. The four sections included:

Table 1.

Interview protocol and sections.

Section	Questions
Introduction: sociodemographic characteristics	Age, Place of birth, Marital status, Level of education, Economic level
Benefits of telehealth for the elderly people	Do you have a computer at home? A tablet? A smartphone? An internet? Do you normally use a computer / internet / smartphone to shop online? To log into your bank account… or for other things? Do you normally use digital/virtual services for medical matters? In some cases, would you prefer using such services to talk to your primary care physician in person? What virtual services have you used in the past (before the Corona phase)? Do you think such services could be beneficial for the elderly population? What benefits, if any, does telemedicine have for the population in general and the elderly population in particular? What are the benefits, if any, of telemedicine during the coronavirus pandemic?
Difficulties and obstacles in telehealth usage	During COVID-19, did you require medical advice or treatment that was denied to you for social distancing reasons? Did you use any of the telemedicine services during this period [e.g., video and/or telephone visits/conversations with the medical provider or with a consultant outside of office hours, electronic medical records/electronic check-in, electronic refill of a medication, electronic request for referral to a specialist, exchange of electronic messages with the medical provider, and other remote/virtual health care services], and if so, what was your experience with them? Have you had any particular difficulties using these services, and if so, what were they? What is the greatest difficulty you have had or would like to have in using these services? Have you used or wanted to use a family member to use these telemedicine services? What, if anything, is keeping you from using telemedicine services during the coronavirus pandemic? Did the Covid 19 period change anything in your attitude about the importance of using telemedicine services for the elderly population? Did you feel that it was easier to use these services during the COVID-19 pandemic? Did the effort to use these services diminish during this time? Do you feel that the accessibility/availability of telehealth services changed as a result of your experience during the COVID-19 pandemic? Did your experience with these services during the COVID-19 pandemic lead to a change in your attitude toward the efficiency and feasibility of using these services on a permanent basis, rather than just during the COVID-19 pandemic?
Suggested recommendations and solutions	What do you think can be done to improve the accessibility of telehealth services to the elderly population to make it easier for them to use these services? If you could design strategies to improve telehealth for the care of the elderly population during the pandemic COVID-19 and in routine times, what suggestions would you have for improving telehealth?

• The introductory section included general questions on sociodemographic characteristics (age, place of birth, marital status, level of education, economic level).

• The first section included questions about the use of digital solutions for everyday purposes and for health issues, the benefits of telehealth for the elderly population, and their use of telehealth solutions during the COVID-19 period.

• The second section included questions about the difficulties and obstacles they may encounter in using telehealth services and whether they have noticed a change in their accessibility during the COVID-19 period.

• The third section included questions about their recommendations for possible solutions aimed at improving the use of telehealth solutions for the elderly population, in normal times and not just during pandemics.

Data analysis

Our goal was to reflect and describe the reality of participants’ experiences of using telemedicine services. We were interested in the personal experiences, feelings, and insights of individual participants. As previously explained, we used thematic analysis, a flexible research tool that allows for a rich representation of qualitative data. ¹⁷

We followed the SRQR, which describe the process by which themes are identified and developed. According to the SRQR, techniques for improving the trustworthiness and credibility of data analysis include researchers first developing themes independently, reviewing and revising each other's themes, and maintaining an audit trail of original and revised themes. ¹⁵

A qualitative content analysis, which is a methodical way of gathering and examining qualitative data, was used to examine the responses. ¹⁸ The objective of this technique is “to answer questions such as what, why and how, and the common patterns in the data are searched for” by using a consistent set of codes to organize text with similar content and producing themes and subcategories within themes from participant replies. ¹⁶ We used the inductive approach of qualitative content analysis, which is appropriate when prior knowledge regarding the phenomenon under investigation is limited or fragmented. In this approach, codes, categories, or themes are directly drawn from the data. ¹⁶

To assess whether the themes accurately reflected the original data, they were evaluated against the original transcriptions to ensure coherence.

The analysis procedure involved several stages: in the first stage, after reading each participant's transcribed interview, each author independently identified and categorized themes for each portion of interview protocol and compiled them into a list of themes.

The researchers convened as a group in the second stage to review each participant's interview as well as the themes that had been previously identified by each of the writers. This was done after each member had finished developing themes and subcategories. The authors explored themes that each member may have overlooked or perceived differently as well as common themes and subcategories among the members.

In the last stage, the themes for which approval had been gained were finally combined into a table and master document that expressed the group's collective understanding. When no new themes or subcategories appeared and consensus was reached among the participants through discussion, the analysis was deemed to be complete.

The themes and the subcategories within the themes were arranged in a table according to the three different topics on which they were queried. In order for readers to evaluate the coherence of the data and our interpretations, we gathered a few chosen quotes.

In order to evaluate the consistency of the information and our conclusions, we gathered a selection of carefully picked quotes (which are presented both in the text and in more detail in a separate table).

Results

Participants

Fourteen elderly people were recruited for the study and interviewed in person by the first author between September 2022 and the end of January 2023 using a semiconstructive questionnaire protocol.

The mean age was 73 years, range 66 to 85 years, 6 men and 8 women. The characteristics of the participants are shown in Table 2.

Table 2.

Participants’ descriptions and characteristics.

Serial number	Gender	Age	Religion	Cultural subgroups	Marital status	Socioeconomic Status	education	Chronic diseases
1	Male	70	Jewish	Ashkenazi	Married + 4	Average	Bachelor's degree	BPH
2	Female	70	Jewish	Sephardic	Divorced + 3	Average	Secondary	FMF, fibromyalgia, OA
3	Female	73	Jewish	Ashkenazi	Married + 4	Above average	Secondary	HTN, DM, hypercholesterolemia
4	Male	85	Jewish	Ashkenazi	Widower + 3	Average	Secondary	Glaucoma, valvular heart disease
5	Female	76	Jewish	Ashkenazi	Widower + 3	Average	Bachelor's degree	HTN, AF
6	Male	71	Jewish	Ethiopian	Married + 7	Average	Primary	DM, HTN
7	Female	75	Jewish	Ashkenazi	Widower + 2	Average	Master's degree	—
8	Female	70	Jewish	Ashkenazi	Married + 3	Average	Secondary	DM, HTN, hearing loss
9	Female	72	Jewish	Ashkenazi	Married + 3	Average	Secondary	DM, HTN, hypercholesterolemia
10	Male	81	Jewish	Ashkenazi	Married + 2	Above average	Secondary	IHD, AF, hypercholesterolemia
11	Male	77	Jewish	Ashkenazi	Married + 3	Average	Bachelor's degree	HTN, DM, aortic aneurism
12	Female	66	Jewish	Ashkenazi	Married + 3	Above average	Secondary	HTN, hypercholesterolemia, breast cancer Hx
13	Male	70	Jewish	Ashkenazi	Married + 3	Above average	Secondary	Valvular heart disease, CVA, PTSD, DM
14	Female	67	Jewish	Sephardic	Widower + 6	Below average	Primary	CVA, thyroid Disease, HTN, hearing loss

Primary = elementary school.

Secondary = high school.

BPH: benign prostatic hyperplasia; FMF: Familial Mediterranean fever; OA: osteoarthritis; HTN: hypertension; DM: diabetes mellitus; AF: atrial fibrillation; CVA: cerebro vascular accident; PTSD: post-traumatic stress disorder.

The participants’ characteristics were diverse, including their ages, occupations, genders, level of education, SES, locations of residence, family status, and health status.

The duration of the interviews varied from 40 minutes to 1.25 hours.

Researchers’ reflections

As the study's principal investigator, MH designed the investigation and conducted all of the interviews by himself. He had the chance to request an approval from Clalit committees since he served as a physician working for Clalit health services at that time. He had a very significant experience with telemedicine, actively participated in pediatric telemedicine services, and completed a PhD thesis on the physician decision-making process in pediatric telemedicine services. He also had a lot of experience conducting qualitative research. ¹⁹

Despite the fact that he served primarily as a pediatrician and medical director, MH was aware of the challenges that the senior population faces when using telemedicine services, especially during the COVID-19 time. During this time, his mother (RIP) was injured, suffering a head injury. Because of the limits imposed by COVID-19, he was unable to visit her while she was being treated in a rehabilitation hospital. The hospital nurses’ use of a tablet to make a video call was the only option available. This historical period highlighted the great value of telehealth for the elderly, both in normal times and during pandemics, in particular. In addition, as a member in the health disparities working group, in the International Society for Telemedicine and e-Health (ISfTeH), the issue of health disparities was especially important to him.

Apparently, different dynamics shaped MH's interactions with old people interviewed by him, and they likely perceived that he had a lot of sympathy and compassion for their struggles.

The principal researcher was able to see the data through the eyes of the elderly thanks to the interviews, which challenged preconceived notions. The key to this was having a good rapport with the elderly individuals that were interviewed.

The other researchers involved in this study had excellent experiences using telemedicine studies and services. Each author separately identified and categorized topics for each part of the interview protocol, as was previously mentioned, and then put those themes together into a list of themes. In the following phase, the researchers gathered as a group and went through each participant's interview as well as the themes that each researcher had noted. The common underlying themes and subthemes were ultimately determined.

Research frequently involves patients, caregivers, family members, and service users; nevertheless, during data analysis, their viewpoints and perspectives could be lost. Because they are involved in the process and the research issue, researchers—despite their reflective nature—perceive the world through the lenses of researchers or clinicians. By providing a clear and transparent coding scheme and outlining the data analysis process, this study was made more rigorous and transparent.

The participants’ evocative descriptions of their experiences utilizing telehealth services left each researcher in awe. Although many participants valued the use of online services, many also highlighted the downsides of using telehealth services, stated having significant difficulty in using them, and suggested ways to overcome these barriers.

Data analysis

Analysis of the data from the interviews revealed several themes related to the three main topics on which the elderly participants were asked:

1. Benefits of telemedicine for the elderly population;

2. Challenges and barriers to using telemedicine; and

3. Suggestions for overcoming the difficulties.

The major themes and subthemes are shown in Table 3.

Table 3.

Summary of main themes and subthemes.

	Subject	Themes	Themes’ subgroups
1	Benefits of telehealth for the elderly population	Improved accessibility and availability of medical services	Safe accessibility in times of Corona
		Saving effort and time
		Social and mental help	Helps with the feeling of loneliness
2	Challenges and barriers in using telehealth	Being concerned that the quality is inadequate	Lack of trust in telemedicine services
			Lack of enough time
			Lack of in-person interaction and communication
		Technological difficulties
		Physiological difficulties	Physical difficulties
			Mental difficulties
		Literacy difficulties
3	Suggested ways to overcome the difficulties	Virtual visits initiated by the attending physician
		Friendly and simple solutions
		Special trainings in the clinic
		Tutorials at home
		Distribution of informational material
		Less bureaucracy, more administrative relief

Table 4 displays all of the participant quotes in their entirety, according to the major themes and subthemes.

Table 4.

Participants’ citations within the major themes.

Topics	Major Themes	Citations
Benefits of telehealth for the elderly population	Improved accessibility and availability of medical services	Participant (4): “Some of the elderly people I know are alone, receive no assistance from their families, and find it difficult to travel to the clinic, so telemedicine can be beneficial in that regard.” Participant (14): “When Corona is present, people are afraid to go to the clinic.” Participant (10): “I felt certain that these services would be tremendously beneficial to the elderly. My opinion on the subject was further solidified by the Corona era." Participant (12): “The COVID-19 pandemic made it clear to me that I needed to look after myself and that many tasks could be completed at home, therefore demonstrating their critical value.” Participant (13): “I spoke to the psychiatrist online and had an excellent experience with these services during the COVID-19 pandemic.”
	Saving effort and time	Participant (2): “That might spare me a great deal of work. I won't need to leave my house to see the doctor. Nowadays, clinics have lengthy wait times. I'm considering signing up for a telemedicine program for people with heart conditions (SHAHAL).“ Participant (9):” If these services are good, it can save time and effort.” Participant (10): “This can help older people receiving immediate treatment instead of delaying and dragging their feet.”
	Social and mental help	Participant (1): “Because many seniors are lonely, the virtual visits can aid the elderlies not only in the physical aspect but also in the mental and social elements.”
Challenges and barriers in using telehealth.	Being concerned that the quality is inadequate	Lack of confidence in telemedicine services:  Participant (7): “I believe face-to-face is the best care…”  Participant (1): “I am a member of the older generation. I enjoy speaking with the doctor in person and asking him questions.” Insufficient time allotted for the virtual meetings:  Participant (1): “I think that there is more time in face-to-face meetings.” The absence of in-person interaction and communication:  Some participants felt that they could process information better during face-to-face visits:  Participant (1): “It didn’t feel very personable…”  Participant (3): “I'm a little wary of these services. I am a very communicative person and there is a fear that in such a meeting I will feel lost, both in terms of communication and technology.”  Participant (2): “In-person visits are better for me. When you're not in the same room as your doctor, you lose the connection and the ability to feel empathy.”  Participant (5): “I prefer to meet with the doctor in person because I am alone at home and feel lonely, not because connecting remotely is difficult.”  Participant (8): “I used a variety of internet resources and online services, particularly when I needed to learn about some medicine side effects, but I still prefer face-to-face interactions so I can speak with a doctor directly.”  Participant (11): “I prefer face-to-face meetings where it seems as you wouldn't be talking to a ‘dummy’ and it's easier to ask questions and get answers.”  Participant (14): “I prefer a face-to-face encounter since it feels less intimidating and makes it simpler to ask questions and get answers.”
	Technological difficulties	Participant (11): “We just couldn’t get it to work (the video session). It was frustrating and irritating, to say the least.” Participant (12): “Connection issues, trouble accessing records (keeps me from using it).” Participant (2): “I find it quite challenging, it was very difficult for me, especially with the video meeting. I have no idea how to use the software.” Participant (6): “It is difficult to get on the computer with all the passwords needed.” Participant (8): “ It doesn't flow. As soon as I encountered difficulties once—I will not try to connect again.” Participant (10): “Even though I typically understand technology, there were still issues because the system's programming was subpar and did not provide the chance to select the correct option…In addition—during the COVID-19 pandemic—there was a negative experience because several appointments were made for different people at the same time.”
	Physiological difficulties	Participant (2): “I have memory and comprehension issues.” Participant (14): “I have difficulties in managing and operating things required for the online connection.”
	Literacy difficulties	Participant (13): “The information is still there but I still acquire information better in person…” Participant (3): “I don't always understand everything, and when it comes to remote communication, I don't always trust myself to understand everything. In a face-to-face meeting I am very verbal.” Participant (8): I have difficulties in understanding the instructions. I am using a family member even to help me scheduling an appointment online.” Participant (6): “There are numerous challenges, particularly for elderly Ethiopians because we are not tech savvy.”
Suggested ways to overcome the difficulties.	Virtual visits initiated by the attending physician	Participant (1): “I believe it would have been much simpler if the doctor or nurse had begun proactive virtual visits.”
	Friendly and simple solutions	Participant (3): “Whenever feasible, friendly and straightforward solutions should be offered rather than merely the advice to ‘get an app.” Participant (8): “The tools and procedures should be made simpler. It shouldn't require constantly switching to another screen and should be easy to use. When I have an urgent inquiry, I'm still trembling and anxious, therefore it must be as straightforward as possible.” Participant (12): “We need straightforward gadgets with user-friendly apps, ideally with graphics and pictures.”
	Special trainings in the clinic	Participant (7): “Elderly persons should have some particular classes and workshops where they will be provided explanations and demonstrations on how to use these services.” Participant (6): “An employee of the healthcare system, such as a social worker, nurse, or computer specialist, should directly instruct elderly patients in the clinic on how to use these services.” Participant (13): “They ought to set up a presentation, a lecture, or evening of knowledge where they would outline and show usage.”
	Tutorials at home	Participant (4): “There ought to be someone who can come to our homes and repeatedly demonstrate how to use these items. As we are unfamiliar with modern technology, the elderly Ethiopians need additional assistance. We should receive tablets that are simple to use.” Participant (10): “These services ought to be more friendly to use and easier to utilize. Somebody should be paid to be tied to elderly individuals who can explain how to use these tools.”
	Distribution of informational material	Participant (9): “I believe that brochures that provide written instructions on how to use the telemedicine services should be available. Also, a clinic employee might demonstrate how to utilize them for us.”
	Less bureaucracy, more administrative relief	Participant (11): “The most crucial thing is that there should be an improvement in the Israeli bureaucracy, more administrative relief in Israel and not just technological advancements.”

Here, chosen quotes from the participants’ comments that correspond to each theme are provided.

Use of telemedicine services during routine and COVID-19 pandemic and benefits of telemedicine for the elderly population

Most participants reported using at least one of the telehealth services during the COVID-19 period, mostly for administrative purposes or for discussions with their primary care physician.

Some of them had good experiences, but some didn't feel that it was easier to use during this period, contrary to their expectations:

Participant (11): “during the COVID-19 pandemic - there was a negative experience because several appointments were made for different people at the same time.”

Participant (8): “the services and application were not easy to use even during the COVID-19 pandemic … I did not feel like anyone made an effort to make it easier for us.”

The participants discussed the advantages of telehealth, which included reducing exposure to COVID-19, saving time, and effort on trip, having access to high-quality treatment, using a cost-effective means to obtain care, and even offering the elderly the mental and social support they need.

Theme 1: Improved accessibility and availability of medical services

Participant (4): “Some of the elderly people I know are alone, receive no assistance from their families, and find it difficult to travel to the clinic, so telemedicine can be beneficial in that regard.”

Theme 2: Saving effort and time

Participant (2): “That might spare me a great deal of work. I won't need to leave my house to see the doctor. Nowadays, clinics have lengthy wait times. I'm considering signing up for a telemedicine program for people with heart conditions…”

Theme 3: Social and mental help

Participant (1): “Because many seniors are lonely, the virtual visits can aid the elderlies not only in the physical aspect but also in the mental and social elements.”

Challenges and barriers to using telehealth

The majority of participants reported having a smartphone, computer, and internet access at home, and some of them use online services for things like shopping, checking their bank accounts, and other things.

Although many participants acknowledged that they use a variety of online services, including scheduling medical appointments online and renewing routine prescriptions, many of them still had difficulties with telehealth (particularly video meetings) and emphasized the drawbacks they saw in using it.

Despite the fact that telemedicine services were most in demand during the Corona era, the majority of participants didn't believe there had been a significant change or improvement.

Theme 1: Being concerned that the quality is inadequate

Many participants expressed concern that the quality of telemedicine sessions may not be good enough compared to in-person sessions.

Several of the participants made explicit mention of a number of areas about which they were worried. For example, lack of confidence in telemedicine services:

Participant (1): “I am a member of the older generation. I enjoy speaking with the doctor in person and asking him questions.”

Insufficient time allotted for the virtual meetings:

Participant (1): “I think that there is more time in face-to-face meetings.”

The absence of in-person interaction and communication:

Some participants felt that they could process information better during face-to-face visits:

Participant (3): “I'm a little wary of these services. I am a very communicative person and there is a fear that in such a meeting I will feel lost, both in terms of communication and technology.”

Theme 2: Technological difficulties

Many participants highlighted the technological challenges in the use of computers and applications in general and in the context of healthcare in particular. For example:

Participant (11): “We just couldn’t get it to work (the video session). It was frustrating and irritating, to say the least.”

Theme 3: Physiological difficulties

Participant (2): “I have memory and comprehension issues.”

Theme 4: Literacy difficulties

Participant (3): “I don't always understand everything, and when it comes to remote communication, I don't always trust myself to understand everything. In a face-to-face meeting I am very verbal.”

Suggested ways and solutions to overcome the difficulties

The participants suggested a number of ways to increase the accessibility and use of telemedicine solutions by the elderly, including: (1) streamlining and simplifying the telemedicine infrastructure; (2) providing educational sessions, classes, and tutorials on how to use remote care, by medical personnel, at home or at the medical provider clinic; and (3) providing advertisements and special flyers with straightforward explanations for the elderly. For example:

Participant (1): “I believe it would have been much simpler if the doctor or nurse had begun proactive virtual visits.”

Participant (9): “I believe that brochures that provide written instructions on how to use the telemedicine services should be available. Also, a clinic employee might demonstrate how to utilize them for us.”

Participants (8): “ The elderly should receive some simple-to-use tablets.”

Participant (7): “Elderly persons should have some particular classes and workshops where they will be provided explanations and demonstrations on how to use these services.”

Discussion

The current study, which employs a qualitative methodology, looks into the challenges and impediments that Israel's senior population encounters when utilizing telemedicine.

Although the majority of participants understood and appreciated the potential advantages of using telehealth services, in routine days, and particularly during pandemics, most of them also acknowledged a number of challenges and barriers to doing so.

They offered suggestions for how to make telemedicine services more accessible to and useful for the elderly.

Telemedicine is well known to have several advantages, especially when it comes to providing healthcare to disadvantaged communities and places, increasing accessibility and lowering health disparities. Where possible, the health system should offer virtual medical care so that patients can remain at home and yet have access to the necessary medical treatment, especially during lockdowns and pandemics. ²⁰

A variety of factors have been identified as potential barriers to telehealth for elderly people. These obstacles, which might include technological difficulties as well as health concerns, personal situations, and literacy issues, could put older patients at a digital disadvantage. It is generally known and well-documented that older persons face a digital divide that makes adopting telemedicine difficult.^7,21–25

Yet, a number of studies and surveys revealed that even the older population had a high level of satisfaction with the telemedicine services offered.^26–28 Furthermore, prior research has demonstrated that, despite older age being linked to a decline in technological familiarity, interest in telemedicine remained unaffected. ²⁹

The use of telemedicine has grown over the past few years in the United States and other nations.^30,31 The COVID-19 pandemic forced a rapid expansion of telemedicine use among patients and providers. During this pandemic, telehealth has been essential in the provision of healthcare. Patients have had access to continuity of care thanks to these technologies, which also work to reduce viral exposure. Due to waivers from the Centers for Medicare & Medicaid Services and other insurance companies that have lowered limits on the use of telemedicine and enhanced payment parity relative to in-person consultations over this time, the availability of telemedicine has expanded dramatically.^32,33 This quickening of telemedicine is also consistent with Israel's strategy of promoting digital services and ensuring that they are advanced, inventive, sustainable, and always developing and improving.

I n the first section of the interviews, the participants talked about the importance and advantages of telehealth services as well as their personal experiences utilizing them in Israel during the Corona era. The advantages were primarily the ability to obtain high-quality care from a distance, savings in travel time and effort, minimized exposure to COVID-19, and even offering the elderly the emotional and social support they need.

Providing the emotional and social assistance that the elderly population require, particularly during pandemics and periods of social isolation, is one of the unique advantages of telehealth that the study participants described.

Patients can receive care remotely through telemedicine visits, which also lower the risk of infectious exposure for those who are more susceptible to it and make it simpler for them to access care by cutting down on the costs, difficulties associated with transportation, and amount of time required to see an outpatient provider.^34,35

Telemedicine services have the potential to enhance health outcomes, accessibility and timeliness of care, and chronic illness management at home when used effectively.^36–38 However, it is critical to clearly communicate the role of telemedicine in enhancing, not displacing, in-person care as it becomes a more important part of contemporary healthcare delivery^39,40—even beyond the epidemic.

In the second section of the interviews, the study's participants discussed the challenges and barriers they face when adopting telemedicine: The biggest obstacle was their lack of confidence in telemedicine services, particularly the absence of face-to-face conversation and engagement. Several of them preferred in-person consultations with their doctor for this reason. This obstacle falls under the category of “intrinsic” barriers since it results from participants’ internal perspectives and fears.

The interaction and relationship between patients and doctors are a concern with regard to the utilization of telemedicine. Several research discuss the relationship between patient preference for telemedicine and doctor familiarity. The patient–physician interaction was emphasized by patients in these studies and was the deciding factor in whether they wanted face-to-face care or telemedicine.^41,42

Older persons may be reluctant to use telemedicine because they might think that telemedicine visits are inferior to in-person care because the virtual visits do not allow for human touch. Humans appear to need to establish an emotional connection or “emotional loyalty” with the caregiver in order to feel like they are a part of the relationship; in contrast, telemedicine may be seen as being rather “cold” and alienating, and as a result, patients may choose not to use it. Consumers of healthcare must have this “emotional loyalty,” which is defined as the “psychological preference for a brand that comprises of favorable feelings and affective connection that enables its purchase or use in the future.” ⁴³

This is in line with findings from a national study in the United States, of older individuals, who expressed limits in physical exams and concerns about a drop in treatment quality as their main objections to telemedicine. ⁴⁴

However, as also noted in our study, older adults are more likely to continue using telemedicine as a component of their care after a positive experience with a telemedicine visit, particularly when it allows them to connect with their personal doctor, with whom they have already developed in-person relationships. ⁴⁵

The participants mentioned technological hurdles as additional challenges. These issues can be referred to as “extrinsic” problems.

The biggest challenges were not knowing how to connect to the platform (particularly for video meetings), being unfamiliar with the technology, and thinking that it is too complicated and cumbersome, and does not cater to the needs of the senior population.

For the exchange of information between parties, telehealth depends on technology, which presents a challenge for older persons who may not have access to the required electronic equipment and services. Without these tools or a technology mindset, telehealth is restricted to phone calls, which may be adequate for straightforward services (such medicine refills) but has limitations for more complex treatment. As was previously mentioned, even when older persons have access to technology, issues can still occur if they lack technical expertise, are unable to solve difficulties as they occur, or are unable to adjust to digital communication. ⁴⁶

Patients’ lack of digital literacy was identified as a significant telemedicine obstacle in a physician study on the effects of telehealth. ⁴⁷ In addition, a study on telehealth preparedness in persons over 65 indicated that 30% were unprepared for telehealth encounters due to a lack of technological experience. ⁷

Similar to other studies,^22,29 the participants in our study appeared to be more accustomed to telephone platforms than online video ones, and it becomes significantly more difficult for them to set up telemedicine platforms for video visits. This is primarily because they are unfamiliar with video and internet technology and because learning new technological skills is difficult.

The digital divide is also a result of older people's e-health literacy gaps and challenges. The participants in our study also mentioned potential literacy issues the elderly may have, as was previously observed.^{7,21–25,48,49}

However, recent research suggests that the share of older persons using digital technologies is rising,^50,51 despite the fact that other studies show that the digital divide is still a significant problem.^{21–25,48,49}

The difficulties in telemedicine adoption for older persons are also a result of the potential functional deficiencies in hearing, vision, memory, and cognition that this demographic may have, ⁷ as stated by some study participants.

The problems with literacy and daily functioning are similarly also “intrinsic” in their origin (as the lack of confidence previously described).

According to a recent study, ¹⁰ “about two-thirds of patients aged 70 years or beyond have clinically substantial hearing loss.” Hearing loss is practically universal among older people. In addition, many elderly persons deal with cognitive decline. The most well-known type of cognitive impairment, Alzheimer's disease, may currently affect 5.1 million Americans aged 65 or older, according to the Centers for Disease Control and Prevention. ⁵²

Although socioeconomic inequalities and language barriers have been previously well-documented as having an impact on the use of telemedicine,^7,10,53,54 in our study, those factors were not reported by the participants, but they undoubtedly may have an impact on how the elderly population uses these services.

The third section of the interviews focused on participant suggestions for how to make telehealth services more usable and accessible to the elderly. The key components of these proposed solutions were the requirement for telemedicine infrastructure simplification and the requirement for medical professionals to provide education sessions, workshops, and tutorials on how to use remote care.

While not all elderly people experience telehealth difficulties, those that do are unable to completely benefit from virtual care, if at all. This fact could have significant effects; however their full scope is not yet known. It is conceivable for crucial therapies to be put off or never administered, for significant medical conditions to go untreated, and for diagnoses to be delayed.

In spite of the fact that elderly patients can gain the most from using telehealth services to increase their access to care during the COVID-19 pandemic, a recent systematic review ⁵⁵ found that not enough telehealth solutions are tailored for or focused on the requirements of this particular population.

Several telehealth disparities-related problems are complicated and call for systemic responses to public health. Yet, healthcare professionals who handle elderly patients can also put useful tactics into practice to ensure that these patients have positive experiences with virtual care. These tactics can be used prior to, during, and following telehealth interactions.^10,56,57

The main obstacles are related to technology, but they might be removed with training, utilizing change-management strategies, and using a combination of direct patient-to-provider contact and telemedicine. It is crucial to ensure that platforms are simplified and simple to use, or to think about embracing platforms that have already gained significant societal popularity. It will also be beneficial to provide caregiver training and on-demand telephone or in-person support for troubleshooting, as many older individuals rely on their caregivers and adult children for technology support.

A study from 2019 ⁵⁸ investigating the feasibility of telehealth in a homebound population of older New Yorkers found that one home-based primary care program practice was able to complete video-based telehealth encounters with only 8% of their “medically stable” patients. According to the authors, it is important to find the right patients for whom video visits can replace in-person visits, and this involves a number of technical and practical challenges that require further work. In addition, the authors conclude that the availability of standardized Wi-Fi-enabled devices and enhanced internet would lessen the discrepancies regarding the ability of patients and caregivers to take part in telehealth services.

Better results were demonstrated in a study done on a large home-based primary care program in New York City that served 873 community-dwelling homebound patients. ²³ and 35% of those patients had their first video-based telehealth encounters between April and June 2020, during the first COVID-19 surge in NYC. Although the findings show that it is possible for this population's use of video-based telemedicine to expand dramatically and quickly (in just four months), the majority (82%) needed help from a relative or hired caregiver to finish the visit. However, a significant proportion (27%) of homebound patients were unable to participate in telehealth. This underscores the requirement for creative, patient-specific approaches to enhance video-based encounters. The majority of tele-naive patients were judged to be unable to participate in a video-based telehealth interaction on their own, but a sizable portion of these patients also had a caregiver on hand who could help them. Patients who are not accompanied by carers may benefit from novel methods, such as community health workers’ assistance with video-based telehealth consultations.

Limitations

This study is community-based and has some restrictions. The study's participants may not be universally representative of all older adults living in all locations and nations.

We selected this primary clinic in an effort to reflect a range of ages, genders, and socioeconomic backgrounds while better understanding the access obstacles to telemedicine for independent seniors living in their own homes.

Given that participation in the study was voluntary and that the results only reflect individuals who were available and willing to participate, there may also be some degree of selection bias.

Although the number of participants may seem modest, as previously said, we felt that we had reached “saturation” and that adding additional people would not result in the addition of any new insights.

Conclusions

Older persons may encounter a number of challenges in using telehealth that might impede necessary care and treatment, especially when access to in-person care is constrained. As telemedicine use diminishes, an already vulnerable population—such as the elderly population—is exposed to greater healthcare inequities.

In our study, even though most participants recognized the advantages and potential of telehealth services, particularly for the elderly population during pandemics and normal times, most of them also expressed the various challenges that face the elderly population in using these services, despite the fact that they stand to gain the most from these solutions.

On the one hand, these obstacles can be classed as “intrinsic” obstacles, such as a lack of confidence in telehealth services, a lack of technology experience, hearing, vision, and/or communication impairments, cognitive problems, and a lack of e-health literacy. On the other side, there are also “extrinsic” impediments, those brought on by the healthcare system itself, such as limited access to technology and technical issues resulting from the convoluted, unfriendly and even hostile telehealth systems being deployed.

Although the “extrinsic” difficulties are easier and simpler to handle (by increasing the number of telehealth services and applications created specifically for the elderly population and making their use simpler), the “intrinsic” difficulties can also be treated, by explaining the value of telemedicine and how to use these applications to the elderly, improving their e-health literacy and providing the necessary confidence in these services.

There is a need to spread knowledge and information about each service's availability, use, and benefits over in-person consultations, as well as identify obstacles that prevent patients from using telemedicine. This arises from the fact that a sizable part of the elderly still prefers in-person consultations with doctors.

Elderly people can also gain from having a caregiver who can assist them in improving telehealth (particularly video-based) engagements. Patients without caregivers may benefit from novel approaches, like the help of community health professionals.

Patient virtual interactions can be optimized, and care disparities can be addressed with proactive methods for identifying and removing telehealth hurdles. To help policymakers develop policies to encourage the adoption of telemedicine services in the older population, while addressing potential current gaps and examining opportunities to facilitate their use, further studies are required on this subject.