Associations Between Telemedicine Use Barriers, Organizational Factors, and Physician Perceptions of Care Quality

Abstract

Introduction:

Evaluating physician perceptions of telemedicine use and its impact on care quality among physician providers is critical to sustaining telemedicine programs, given the uncertainty of reimbursement policy, preferences, inadequate training, and technical difficulties. Physicians reported technical barriers to effectively practicing integrated medicine using telemedicine as patient volumes increased during the pandemic. The objective of this work was to examine whether perceived practice barriers and facilitators were associated with physician respondents’ perceptions of telemedicine care quality compared with in-person care.

Methods:

This cross-sectional study analyzed the 2021 National Electronic Health Record Survey. The sample comprised 1,857 nonfederally employed physicians (weighted n = 403,013) delivering integrated patient care. Of those physicians, 1,630 (weighted n = 346,646) reported providing care through telemedicine. We reported frequencies and percentages of reported practice characteristics. Generalized ordinal logistic regressions examined relationships between practice factors and care quality for telemedicine care.

Results:

Most of the sample (n = 1,630) were male (66.1%), >50 years of age (66.1%), and worked in a single location (73.5%). A total of 70% of respondents reported that patients had difficulty using telemedicine platforms, and 64% reported limitations in patients’ access to technology. Most respondents indicated having provided quality care to some extent (45%) and to a great extent (26%) during telemedicine visits compared to in-person visits. Associations between barriers, facilitators, and care quality perceptions were positive, underscoring resiliency in telemedicine programs among practices.

Conclusion:

Care modalities and the organizational, environmental, and personal facilitators drive quality perceptions among physicians. Perceived fit and usability determine perceptions of care quality for providers integrating telemedicine into their practice.

Introduction

The COVID-19 pandemic forced health care organizations to rapidly develop and refine telemedicine programs to meet consumer and clinical provider expectations.^1,2 During this time, expanding telemedicine availability represented a solution to reduce physical barriers in care delivery and minimize disease exposure, particularly among patients with historically poor access to care.^3,4 Generous reimbursement environments and readily accessible resources across states generated greater telemedicine use and activity, enhancing and complementing traditional face-to-face visits across care settings and specialties.^5,6 Assessing the appropriateness of telemedicine adoption within certain specialties and patient populations with little exposure to digital health care tools was critical to program success.⁷ However, the surge in telemedicine visit volumes affected access for marginalized patients and organizations with limited slack capacity.⁸ The rapid rise in telemedicine visits also led to variable perceptions among physicians of the usability of telemedicine within their practice, resulting in variable uptake and underscoring the need for flexible models of telemedicine integration to facilitate sustainability.^9,10

Telemedicine can increase access and improve clinical outcomes for individuals and communities. However, provider experiences and perspectives on digital and virtual health care delivery are essential for the quality and sustainability of telemedicine delivery programs. Despite incentives to increase the uptake and use of digital health tools, physician practices have historically lacked resources to expand their health information technology capabilities to comparable levels seen among hospitals.¹¹ Prior research indicates that physician practices lagged larger health care organizations in adopting and using digital health care tools, including virtual care.^12,13 Physicians have generally reported a willingness to utilize hybrid care formats incorporating virtual and in-person care based on patient preferences.^14,15 Organizations have responded to these preferences by ensuring that their digital health care infrastructure is sufficient and aligned with the needs of providers and patients.^1,16 Additionally, digital health care tools have been found to improve care access and quality.¹⁷ Evaluating perceptions of telemedicine use and its impact on care quality is critical to sustaining hybrid telemedicine programs, especially given the uncertainty of state reimbursement policy, evolving patient preferences, inadequate training, and technical difficulties.¹⁸

Access to a broader network of health care professionals facilitated by newly relaxed reimbursement policies enabled patient care continuity despite underscoring existing barriers to care in a largely new delivery format.¹⁹ Lack of access to the necessary technologies by both patients and provider practices limited care delivery even as higher-level structural and financial barriers to telemedicine implementation were removed.^8,20,21 While these barriers are notable, they do not affect provider perceptions of care when delivered through a telemedicine platform. Perceptions are generally positive and indicate that telemedicine was an appropriate tool as determined by providers across specialties.²² However, research examining relationships among telemedicine use, organizational characteristics, structural factors, and provider perceptions of care quality when using telemedicine compared with in-person care is limited.

Objective

The current study examined whether perceived organizational and environmental barriers and facilitators were associated with the quality of telemedicine services among physician practices. We analyzed the relationships between perceived telemedicine use barriers and facilitators, physician practice-level factors, and perceived quality of care for health care services delivered through a telemedicine platform.

Methods

DESIGN AND SURVEY POPULATION

We conducted a cross-sectional analysis of the 2021 National Electronic Health Record Survey (NEHRS). NEHRS is a nationally representative sample of nonfederally employed, office-based physicians actively delivering patient care.²³ The 2021 survey included responses from 1,875 physicians (weighted n = 403,013) who indicated using an electronic health record (EHR) or other related digital health care tool during care delivery. Physicians in this sample also indicated a range of organizational, patient, and policy-related barriers to delivering care through telemedicine. We analyzed deidentified and publicly available survey data, which does not constitute human subjects’ research. Thus, this research did not require the Institutional Review Board (IRB) review. However, we sought IRB approval from the Indiana University IRB and determined that this research is exempt.

PRIMARY INDEPENDENT VARIABLES: PERCEIVED TELEMEDICINE USE BARRIERS

The 2021 survey included questions that asked physician respondents about issues affecting their telemedicine use. Specifically, we identified questions that asked about physician perceptions of barriers and facilitators to the use of telemedicine, including: “limited internet access and/or speed issues,” “limitations in patients’ access to technology (e.g., smartphone, computer, tablet, internet),” “improved reimbursement and relaxation of rules related to use of telemedicine,” “appropriateness of telemedicine for the provider’s specialty and patients,” “aligning telemedicine platform with the needs of providers and patients,” and “patients’ difficulty using technology/telemedicine platform.”

OUTCOME VARIABLE: PERCEPTIONS OF TELEMEDICINE CARE QUALITY

Physician respondents were asked about the quality of telemedicine care compared with in-person visits. Physician practice facilitators and barriers may be associated with perceived care quality when providing patient care through telemedicine versus in-person. The outcome variable in this study was derived from the survey question in NEHRS that asked the following: “To what extent are you able to provide similar quality of care during telemedicine visits as you do during in-person visits?” We then created a five-level ordinal outcome variable using responses to this question: (1) “Fully,” (2) “To a great extent,” (3) “To some extent,” (4) “To a small extent,” and (5) “Not at all.” In secondary analyses, we created a binary outcome variable by combining “Fully” and “To a great extent,” and coded these responses as 1. The response “Not at all” was coded as 0 in this analysis. We hypothesize that organizational facilitators and barriers are associated with perceptions of the quality of telemedicine care compared with in-person care.

CONTROL VARIABLES

Physician, practice, and geographic characteristics were included in our models as control variables. Specifically, we included a primary and specialty care indicator, number of office locations where care is delivered, health care setting type, health care setting/practice size, Medicaid and Medicare status, and ownership. We included a value-based payment indicator to examine whether organizational compliance with federally incentivized payment innovation was associated with perceptions of telemedicine care quality. We also controlled for the availability of resources that might be delivered in some practice settings using practice size. We included this variable to account for practice-level variation in volume that may drive telemedicine use and associated perceived care quality.

ANALYSES

We described physician respondents in the sample using frequencies and percentages. Bivariate relationships were examined and reported using chi-squared tests and t-tests. We estimated generalized ordinal logistic regression models to examine the relationship between perceived telemedicine use barriers and perceptions of telemedicine care quality to determine changes between the five response levels. We clustered analyses at the individual physician practice level using sandwich estimators. We then conducted several robustness tests. First, we modeled the outcome variable as a binary variable to determine changes in effects based on respondents indicating providing any level of quality care through telemedicine. We then separately modeled all organizational barriers to determine whether a mediating effect existed among perceived organizational, patient, and policy-related barriers and facilitators (e.g., improved reimbursement and relaxation of rules related to the use of telemedicine visits.) We performed simple logistic regression analyses to compare effect magnitudes and directions. Results for all regression analyses were reported as marginal effects estimates. Analyses were conducted using R statistical software version 4.3.2.²⁴

Results

Our final sample included 1,630 (weighted n = 346,646) physician respondents who indicated providing medical care through telemedicine and reported perceptions of telemedicine care quality (Table 1). Approximately two-thirds of responding providers were male (66.1%) and older than 50 (66.1%). Most respondents were single-site practices (73.5%) and reported delivering medical (48.3%) and primary care (33.5%) using telemedicine. Responding practices also indicated having participated in the four value-based payment programs: Accountable Care Organizations (27.3%); Meaningful Use Program (24.7%); Merit-based Incentive Payment System (MIPS) (18.9%); and Advanced Alternative Payment Models (4.5%).

Table 1.

Sample Characteristics

CHARACTERISTIC	UNWEIGHTED	WEIGHTED (%)
Total Sample, n	1,630	348,646 (100)
Physician Sex
Female	565	118,256 (33.9)
Male	1,065	230,389 (66.1)
Physician Age Groups
<50 years	595	118,088 (33.9)
>50 years	1,035	230,558 (66.1)
Number of locations
1 location	1,174	256,282 (73.5)
2 locations	317	65,390 (18.8)
3 or more locations	135	25,776 (7.4)
Practice Size
1 Physician	326	83,136 (23.8)
2–3 Physicians	297	61,829 (17.7)
4–10 Physicians	511	105,177 (30.2)
11–50 Physicians	278	49,347 (14.2)
>50 Physicians	218	49,157 (14.1)
Specialty
Primary Care	502	116,633 (33.5)
Medical	832	168,499 (48.3)
Surgical	296	63,513 (18.2)
Insurance
Medicaid	1,402	274,926 (78.9)
Medicare	1,391	289,272 (83)
Value-based payment
Accountable Care Organization	502	95,284 (27.3)
Advanced Alternative Payment Model	72	15,554 (4.5)
Meaningful Use Participation	460	86,055 (24.7)
Merit-Based Incentive Payment System Participation	318	65,756 (18.9)

PERCEIVED BARRIERS AND FACILITATORS AFFECTING TELEMEDICINE USE

Most respondents (70%) indicated that their patients expressed issues using technology and telemedicine platforms (Fig. 1). Limitations were also reported in patients’ access to telemedicine technologies (64%), including smartphones, computers, and tablets. Similarly, there were reported issues with reliable broadband connectivity (33%). There were other limitations to the appropriateness of telemedicine technology for patient and provider use. For example, approximately 26% of respondents indicated that telemedicine was inappropriate for their specialty or type of patients, and 17% reported the platforms were not easy to use and did not meet practice needs. Conversely, 42% of respondents reported improvements in reimbursement and relaxation of rules facilitated telemedicine use.

Fig. 1.

Issues that affect physician respondent’s telemedicine use. This figure shows the percentage of respondents who reported issues associated with telemedicine use. The data reflect the proportion of respondents who indicated that they encountered each issue, regardless of the degree to which they experienced it.

PERCEIVED BARRIERS AND FACILITATORS AFFECTING PERCEPTIONS OF CARE QUALITY

Compared with in-person care, physician respondents reported providing similar quality care through telemedicine to a small extent (21%), to some extent (45%), to a great extent (26%), or fully (5%) (Fig. 2). Respondents who reported patients having issues using telemedicine and associated technologies indicated they could provide similar quality care through telemedicine to some extent (46%), to a great extent (27%), or fully (4%) compared with in-person care (Fig. 3). Respondents who reported limitations in patients’ access to smartphones, computers, tablets, or the internet reported providing quality telemedicine care compared with in-person care to some extent (49%), to a great extent (25%), or fully (5%). Physicians reported providing comparable quality care through telemedicine to some extent (47%), to a great extent (34%), or fully (5%) where they perceived improved reimbursement and relaxation of rules related to the use of telemedicine. Limited internet access and speed issues were not perceived as major barriers to providing quality care through telemedicine. Respondents indicated still providing comparable quality telemedicine care to some extent (45%), to a great extent (31%), or fully (3%).

Fig. 2.

Extent physicians provide similar quality of care during telemedicine visits as done during in-person visits. This figure displays the distribution of responses regarding the extent to which physicians felt they could deliver a similar quality of care through telemedicine compared with in-person visits.

Fig. 3.

Issues that affected telemedicine use and perceived quality of care. This figure presents the distribution of responses regarding issues associated with telemedicine use. Respondents were asked to indicate the extent to which they perceived providing a similar quality of care using telemedicine compared with in-person visits. Responses ranged from “Not at all” to “Fully.”

ASSOCIATIONS BETWEEN PERCEIVED BARRIERS AND FACILITATORS AND PROVISION OF QUALITY TELEMEDICINE CARE

In fully adjusted regression analyses, limitations in patients’ access to technology (ME = 0.006; p < 0.05) and patients’ difficulty using technology or telemedicine platforms (ME = 0.007; p < 0.05) were associated with high-quality care to a great extent when using telemedicine compared with in-person care (Table 2). Although the magnitude of these effects is smaller for respondents who reported Fully providing comparable quality with telemedicine care, the directions of these effects are the same. Limitations in patients’ access to technology (ME = −0.00179; p < 0.05) and patients’ difficulty using technology or telemedicine platforms (ME = −0.00216; p < 0.05) were negatively associated with responses indicating that physicians were Not at all able to provide high-quality care through telemedicine compared with in-person care. Results from our sensitivity analyses support the results from our primary regression models.

Table 2.

Fully Adjusted Generalized Ordinal Logistic Regression Results

	TO WHAT EXTENT ARE YOU ABLE TO PROVIDE SIMILAR QUALITY OF CARE DURING TELEMEDICINE VISITS AS YOU DO DURING IN-PERSON VISITS?
	NOT AT ALL	TO A SMALL EXTENT	TO SOME EXTENT	TO A GREAT EXTENT	FULLY
Limited internet access and/or speed issues	−0.00898	−0.00375	−0.00054	0.00279	0.00103
Telemedicine platform not easy to use or did not meet our needs	−0.00253	−0.00106	−0.00015	0.00084	0.00291
Telemedicine is not appropriate for my specialty/type of patients	−0.00845	−0.00354	−0.00051	0.00280	0.00968
Improved reimbursement and relaxation of rules related to use of telemedicine visits	−0.00111	−0.00464	−0.00668	0.00369	0.00125
Limitations in patients’ access to technology (e.g., smartphone, computer, tablet, internet)	−0.00179 *	−0.00745 *	−0.00105 *	0.00595 *	0.00205 *
Patients’ difficulty using technology/telemedicine platform	−0.00216 *	−0.00897 *	−0.00126 *	0.00717 *	0.00246 *

^* p < 0.05.

^** p < 0.01.

^*** p < 0.001.

Bolded text indicates statistically significant relationships at the 0.05 level.

Discussion

Effectively integrating telemedicine and in-person delivery of health care services is critical to developing sustainable, high-quality digital health care delivery models and physician perceptions of their ability to deliver high-quality care through telemedicine are key factors in that integration. In a national sample of physician survey responses, respondents indicated providing quality care through telemedicine regardless of perceived barriers to delivering such care. Additionally, organizational and environmental facilitators, such as favorable reimbursement policies, bolstered perceptions of the quality of care delivered through telemedicine compared with in-person care. Perceptions of care quality remained consistent even as providers reported patients having issues with hardware, telemedicine components, or quality broadband access. While the consistency of findings may indicate improved organizational supports for delivering care using telemedicine, the wherewithal to provide quality telemedicine care regardless of technical issues was not fully assessed by the survey.

These findings suggested that physicians representing their practices reported moderate-to-high levels of perceived care quality when conducting telemedicine visits regardless of physician age, sex, or specialty. Results are consistent with prior research examining consumer and patient perceptions of care quality when treated through telemedicine.^14,25 This work builds on this literature by examining whether and to what extent organizational and policy-relevant factors affect the physician’s perception of the quality of care delivered when using telemedicine. Sociotechnical implications of physician responses indicate that fit, usefulness, and suitability drive telemedicine use and perceptions of care quality.²⁶ Providers and patients in more resource-rich environments will likely have access to the appropriate equipment (i.e., hardware, broadband access), space, personnel, and organizational policies and support for completing telemedicine visits.²⁷ Physicians generally reported that patient access and use of telemedicine hardware and software were significant limitations to telemedicine care delivery. However, organizational factors such as size, robust technological infrastructure, and personnel likely buttressed physicians’ ability to provide care using telemedicine. These facilitators were essential for telemedicine-supported health care processes despite barriers reported by physician respondents.

Our findings align with recent shifts in preferences during the COVID-19 pandemic among providers and patients who prefer to deliver or receive care through telemedicine.^9,14,28 Exposure and experience using telemedicine enabled physicians to become facile and familiar with appropriate modalities that supported high-quality care delivery.^9,14,28 While experience and usability depended on physician specialty in prior research,⁹ there were no notable differences in the current study. Younger providers were more likely to utilize telemedicine in the course of care delivery during and after the pandemic.^9,18 Our sample was older, on average, than analyzed in past research, indicating that telemedicine is becoming commonplace in clinical settings among all provider age groups. The shifts in preferences toward telemedicine and hybrid care delivery cannot wholly be attributed to the pandemic; however, disruptions to care models were catalyzed by the need to provide high-quality care virtually to limit disease exposure. The effects of those disruptions have had broad implications for modern health care delivery, access, and care quality.

LIMITATIONS

Our study has several limitations. We conducted cross-sectional analyses of survey data, which limited our ability to determine causal relationships. Although our sample was derived from a nationally representative dataset of physician practices, findings from this study cannot be generalized to other settings in which telemedicine care is delivered. The self-reported survey data may subject findings to social desirability and selection biases. This is particularly notable given the consistent reporting of high-quality telemedicine care delivery regardless of organizational or technical barriers. We could not observe clinical care quality outcomes due to data limitations. However, prior research has examined applicable quality outcomes, such as readmission avoidance among heart failure patients, providing a more straightforward, substantive connection to telemedicine care provision compared with in-person care.²⁹ Lastly, the analysis did not consider patient perceptions of care quality and may indicate differing experiences not noted in this study. This is underscored by physician respondents indicating patients reported difficulty accessing and using telemedicine technologies.

Conclusions

Among physicians, care modalities and organizational, environmental, and user facilitators drive quality perceptions. Sociotechnical considerations, such as perceived fit and usability, determine providers’ perceptions of care quality when integrating telemedicine into their practice. Future research is needed to examine how these factors influence physician perceptions as the policy and payment environments and available technologies evolve.

Authors’ Contributions

K.W.: Conceptualization, Methodology, Formal Analysis, and Writing—Original Draft, Visualization, and Data Curation. A.P.: Conceptualization and Writing—Original Draft. B.B.-P.: Validation and Writing—Review and Editing. J.J.: Validation, Writing—Review and Editing Validation, and Writing—Review & Editing. D.M.: Validation, and Writing—Review and Editing.

Disclosure Statement

Authors have no conflicts of interest to report.

Funding Information

This study was supported in part by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) and National Institutes of Health Office of the Director, (OD), Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) NIH K12HD043441 scholar funds (B.B.-P.), and NIH/NCATS SPROUT-CTSA Collaborative Telehealth Network Grant Number U01TR002626 (D.M.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the sponsors.