Telehealth Utilization in Gastroenterology Clinics Amid the COVID-19 Pandemic: Impact on Clinical Practice and Gastroenterology Training

The Centers for Medicare and Medicaid Services defines telehealth as services including office visits and consultations delivered remotely by an eligible provider using an interactive 2-way telecommunications system (audio and video).¹ Before COVID-19, Centers for Medicare and Medicaid Services paid for telehealth restrictively; however, the emergence of the COVID-19 pandemic resulted in Waiver-1135, extending these services to routine health care to keep vulnerable beneficiaries in their homes, limit community viral spread, and prevent exposure to other patients and staff.¹ This benefit was reciprocated by private insurance carriers. Although these changes provided health care facilities an opportunity to rapidly adopt the remote health care delivery model, the uptake and challenges accompanying this practice change are largely unknown.

We conducted a survey to assess the impact of telehealth adoption on clinical practice and gastroenterology training programs.

Methods

A web-based survey was disseminated among gastroenterology and hepatology providers (ie, attending physicians, fellows, nurse practitioners, and physician assistants) via en masse e-mails, social media promotion, and direct contact by authors. The survey consisted of 50 questions pertaining to adoption, utilization, and barriers to telehealth, and its impact on gastroenterology fellow education. Detailed methodology is provided in the Supplementary Material.

Results

Overview

Two hundred and thirty respondents (71.7% physicians, 21.3% fellows, and 7.4% physician extenders) completed the survey, with 67.8% of responses from academic settings.

During the COVID-19 era, the mean number of weekly half-day clinics for gastroenterology physicians increased (3.18 ± 1.85 to 3.44 ± 2.38; P = .14), but the mean number of patients visits dropped (10.28 ± 4.48 to 6.51 ± 4.28; P < .001).

Adoption

Two hundred and twenty-nine of 230 respondents (99.6%) confirmed adoption of varying degrees of telehealth in their clinical model, with 58.0% ± 32.5% telehealth (via video), 33.2% ± 30.5% telemedicine (via phone) and 10.5% ± 17.8% in-person visits. During this change, patient show rate increased for 36.7% and decreased for 18.1% of respondents, and 45.4% reported a decrease in productivity. With inconsistent clinical support, 50.4% of providers felt abandoned with heightened responsibilities with telehealth.

Provider Perceptions

From a provider perspective, ability to have face-to-face interaction (88.3%), patient trust/satisfaction (57.3%), and sharing screen/image (38%) were the foremost reasons for preferring video vs phone visits; 82.4% of respondents noted that phone was convenient for less technologically inclined populations and had fewer HIPAA (Health Insurance Portability and Accountability Act) concerns (10.7%); and 53.5% of physicians considered level of reimbursement a determining factor.

Provider-perceived telehealth barriers included technical issues with platform/Wi-Fi/Internet connectivity (67.0%), and lack of patient preparedness (42.1%), while the main benefit was less personal exposure to COVID-19 (83.9%).

Future in Gastroenterology

Most respondents (95.2%) foresee a valuable role for telehealth in gastroenterology beyond the pandemic and want to continue if they are reimbursed adequately. Most (80.4%) agreed that institutional advantages (decreased infrastructural cost for clinic space and clinic staff) may favor its adoption and 87.5% believed it could increase access to gastroenterology subspecialists.

Impact on Gastroenterology Training

In gastroenterology attending clinics, fellow participation dropped to <50% with adoption of telehealth, and main barriers included challenges with discussing fellows’ assessment/plan before sharing with patient (48.8%), lack of educational time (48.0%), and shorter clinic appointment times (44.0%).

Gastroenterology fellows’ continuity clinics became “virtual” for 90% of respondents (39% via video; 51% via phone), and in-person visits continued for 21% in a hybrid model. A supervising attending was concurrently involved throughout in only 11.8%, participating for a portion of time in 39.2%; and in 23.5% the fellow completed the virtual clinic and discussed cases/plans with attending at a later time. More than half (63%) of fellows acknowledged having a dedicated discussion time with faculty at the end of each virtual visit or entire clinic session. With these changes, 34.5% of fellows noted a compromise in outpatient gastroenterology educational mission with adoption of telehealth.

Stratified Analysis

Respondents from academic centers reported significantly higher use of telemedicine (via phone) (35.8% ± 29.3% vs 25.3% ± 26.1%; P = .012), and in-person visits were significantly higher in nonacademic settings (15.7% ± 24.5% vs 8.7% ± 14%; P = .008). Use of telehealth (via video) was not significantly different between the 2 settings (56.7% ± 30.5% vs 58.1% ± 31.5%; P = .75).

With respect to geographic variation, use of telehealth (via video) was not significantly different across different regions, although the highest mean percentage use was reported in the West. The Northeast region reported significantly higher telemedicine (via phone) use vs the Southeast (P = .005) or West (P = .004). The Southeast had significantly higher in-person visits than the Northeast (P < .001). The West also reported a significantly higher dedicated time for new-patient encounters (vs Southeast; P = .029) and follow-up encounters vs Southeast (P = .024) and Northeast (P = 0.012). Detailed analysis is provided in Table 1 .

Table 1.

Analysis of Utilization of Telehealth Based on Type of Setting (Academic vs Nonacademic) and Geographical Region of United States

Variable	Total, n (%)	Telehealth (via video), %, mean ± SD	Telemedicine (via phone), % mean ± SD	In-person visits, % mean ± SD	Dedicated clinic time, min, mean ± SD	P value
Type of setting						.012 (for % telemedicine via phone)a .008 (for % in person)a
Academic	156 (67.8)	56.7 ± 30.5	35.7 ± 29.3	8.73 ± 14	New patient: 34.47 ± 10 Follow-up: 23.7 ± 8.5
Nonacademic	74 (37.2)	58.1 ± 31.5	25.3 ± 26.1	15.75 ± 24.5	New patient: 29.9 ± 9 Follow-up: 20.8 ± 7.2
Regionb						.005 (NE vs SE for % telemedicine via phone)c .004 (NE vs West for % telemedicine via phone)c .001 (NE vs SE for % in-person visits)d .029 (West vs SE had higher dedicated time for new patient visit, West had highest % TeleHealth via video, although not statistically significant)d .012 (West vs NE for dedicated follow up time)c .024 (West vs SE, dedicated follow-up time)c
Northeast (NE)	28 (12.2) Academic: 19 (67.9) Nonacademic: 9 (32.1)	50.5 ± 36.3	50.1 ± 33.7	2.67 ± 4.8	New patient: 31.8 ± 9.8 Follow-up: 20.18 ± 7.13
Southeast (SE)	105 (45.7) Academic: 71 (67.6) Nonacademic: 34 (32.4)	57.3 ± 30.1	28.7 ± 26.2	13.73 ± 20.2	New patient: 31.6 ± 8.4 Follow-up: 22.09 ±7.92
Midwest (MW)	37 (16.1) Academic: 32 (86.5) Nonacademic: 5 (13.5)	55.9 ± 23	38.4 ± 22.5	9.1 ± 14.6	New patient: 32.35 ± 10.1 Follow-up: 22.57 ± 7.61
Southwest (SW)	20 (8.7) Academic 11 (55) Nonacademic: 9 (45)	51.9 ± 34.2	29.1 ± 31.5	15 ± 22.4	New patient: 33 ± 11.05 Follow-up: 23.25 ± 9.36
West	39 (17) Academic: 22 (56.4) Nonacademic: 17 (43.6)	65.5 ± 32.7	24.8 ± 30.3	9.6 ± 18.6	New patient: 38.1 ± 11.9 Follow-up: 26.76 ± 8.9

^aUsing independent sample t test.

^bOne respondent did not specify region.

^cUsing 1-way analysis of variance with Tukey’s post-hoc.

^dUsing 1-way analysis of variance with Games Howell post-hoc.

Northeast respondents were inclined toward telemedicine (via phone) over telehealth (via video) compared with the Southeast region, for reasons including less technically inclined population, less platform connectivity burden, and fewer privacy concerns.

Discussion

To our knowledge, ours is the first study from the United States to provide a comprehensive snapshot focusing singularly on telehealth in gastroenterology in response to COVID-19.

Our survey suggests almost universal adoption of telehealth, with 87.9% of 165 physicians reporting >75% utilization in their centers, an increase compared with a recent report in which 47% of centers implemented >75% telehealth.² We also observed a noteworthy variation in utilization of telehealth by region and practice type. This variability might be a reflection of regional influences (higher COVID-19 prevalence in the Northeast and fewer technologically inclined populations in the Southeast). Alternatively, private practice settings may have been poised for a more rapid transition to the economically more desirable telehealth (via video) than academic centers. Our results also demonstrate high utilization of telehealth in gastroenterology fellows’ clinic (90%), but further insight from fellows revealed that training has suffered significantly with this platform, given the lack of consistent supervision in fellows’ continuity clinics and decreased participation in attending clinics.³

Although our overall responses are modest (n = 230), the survey has strong geographic representation (32 states), with an almost equal mix of academic and community centers. The survey was disseminated in late May to ensure providers had adequate time to adapt to telehealth utilization and to sufficiently recognize its benefits and barriers.

While telehealth in gastroenterology has been almost universally adopted, the manner of incorporation into individual gastroenterology practices and training environments has been varied. Although most responders (95.2%) recognize its valuable role beyond the pandemic, many centers (20.6%) plan to completely transition to in-person visits as the country reopens, due to the aforementioned barriers.4, 5, 6 Efficient methods are needed to deliver high-quality patient-centered telehealth care that involves trainees and addresses the systemic challenges to what both providers and patients recognize must be a part of the future of health delivery.