Individual sentiments on telehealth in the COVID-19 era: Insights from Twitter

To the Editor:

Telehealth or telemedicine refers to a remote and virtual platform that assists in clinical practice and health monitoring. Due to the coronavirus disease 2019 (COVID-19) pandemic, telehealth is being rapidly developed and implemented worldwide at an unprecedented rate. In addition, Twitter data signals could help evaluate current public opinion surrounding telehealth during the COVID-19 pandemic, which remains largely unknown; the primary focus of the current investigation is to begin to address this knowledge gap. Specifically, we hypothesize that there may be a large discrepancy in opinions among non-healthcare professional users related to telehealth during the COVID-19 pandemic.

We queried Twitter's application programming interface (API) and obtained all Tweets and hashtags related to telehealth using keywords or phrases (e.g., “tele”, “telehealth”, “telemedicine”), as well as word combinations within Tweets (e.g., “tele” and “health” or “medicine”) between July 1, 2020, and August 1, 2020. We previously described the methodology in detail elsewhere.¹ After excluding Tweets due to retweeting, subject irrelevance, and healthcare professionals' tweets, we analyzed over one million non-healthcare professionals tweets associated with telehealth. We classified tweets into two groups: 1) positive (71.4%); and 2) negative (28.6%) sentiments. (Central illustration) Positive sentiments were mostly generic and could be categorized into four specific views: 1) telehealth is great or very safe and convenient etc.; 2) telehealth is especially beneficial in psychotherapy; 3) telehealth provides the convenience of not using public transportation or spending money on transport or looking for someone to bring them to the clinic; 4) environmental benefit. Negative sentiments were also mostly generic and could be categorized into 5 groups: 1) concern over lack of insurance coverage and negative financial implications; 2) poor broadband internet access for the elderly, rural areas, and the lower socioeconomic strata of patients; 3) cybersecurity and data security, as well as HIPPA privacy concerns; 4) interface or software issues; and 5) most doctor offices want patients to Fax them documents.

To our knowledge, this is the first study utilizing Twitter to identify individuals' perceptions and opinions among non-healthcare professionals regarding telehealth. Our results demonstrate that telehealth-related tweets may be a valuable source of public health research to improve telehealth strategies before and after implementing these platforms into clinical practice. After manual review, we found that tweets related to telehealth from non-healthcare professionals included both positive and negative sentiments, which could be used to guide telehealth platform improvement initiatives.

Overall, we identified four major positive sentiments as it relates to telehealth. Two of the positive sentiments related to safety and convenience and these views were a frequent theme among analyzed tweets. Many comments and tweets included phrasing that developed safety or convenience as general sentiments (e.g., no need to look for someone to bring them to the clinic). Certainly, given the global public health mandate to socially distance in the COVID-19 pandemic, remote telehealth encounters provide a safe and presumably convenient avenue to stay connected with the healthcare system. Although, data regarding telehealth's effectiveness in reducing COVID-19 transmission is limited, a recent systematic review demonstrated that telehealth offers numerous benefits including minimizing direct contact and reducing potential COVID-19 transmission.²

Second, an important positive sentiment that emerged in our study was explicitly related to psychotherapy visits. A significant number of tweets viewed psychotherapy or psychiatry telehealth encounters as beneficial and overall positive. This observation is consistent with previous studies before the COVID-19 pandemic, which have demonstrated that telehealth platform utilization in psychotherapy is not only pragmatic but generally associated with high satisfaction and similar clinical outcomes to in-person psychotherapy.³ As some experts anticipate the need for mental health services to increase during the COVID-19 pandemic, telehealth will continue to be an essential tool to deliver psychotherapy when it may be most needed.⁴

Finally, our analysis demonstrated a significant number of tweets that suggested telehealth platforms would be beneficial for the environment. Telehealth platforms offer individuals the convenience of staying at home, which would contribute to reducing overall transportation that would otherwise occur and in turn reduce air pollution and provide an environmental benefit which has been seen around the globe in recent months.⁵ Transportation challenges have been a longstanding issue in healthcare, limiting access to certain groups, particularly those in underserved communities.⁶ As such, telehealth offers the opportunity to provide needed care to a greater portion of the population, an opportunity that should continue to be capitalized on following emergence from the COVID-19 pandemic.

Data indicates that Twitter users comprise of a racially and ethnically diverse population, with the percentage of users equally divided among White (21%), Black (24%), and Hispanic (25%) individuals.^{7 , 8} Moreover, compared to the general population, a higher percentage of Twitter users, irrespective of race, “say that Blacks are treated less fairly than Whites (64% of Twitter users vs. 54% of Americans)”.⁹ These findings point to a significant opportunity to use Twitter as a platform to deliver a broad array of health information to underrepresented groups, as well as reach an audience who recognizes current societal inequities and may be empowered to become a part of the solution that would create greater health equity moving forward. Five specific categories of negative sentiments emerged among the data analyzed. First, a significant number of tweets included phrasing directed toward financial challenge and grievance. Lack of insurance precluding telehealth was an important concern.¹⁰ Economic hardship during the COVID-19 pandemic has negatively affected access to healthcare in many ways. Notwithstanding, financial hardship and lack of insurance coverage may be an important concern shared by non-healthcare professionals, according to our findings. Again, these issues are of particular concern among individuals living in underrepresented communities.

Another concern identified was technological challenges. These concerns included poor broadband or internet access for the elderly, those in rural areas as well as for the lower socioeconomic strata of patients. Telehealth platforms depend upon internet access in many cases, especially videoconference platforms, which may preclude historically marginalized populations.¹¹ Geographic disparity for telehealth utilization was observed in southern states due to the higher percentage of people in poverty than other regions of the U.S.¹² Thus, various health inequalities may affect telehealth delivery systems and patient concerns surrounding these issues should be considered before telehealth enrollment.

Another concern among Tweets analyzed included cybersecurity or data security and HIPPA law violations as a negative sentiment toward telehealth platforms. Cybersecurity is an important concern within healthcare systems as technology advances, and data breaches are becoming more common and problematic. Given the rapid expansion of telehealth and the numerous technology platforms that could potentially be used, some health care professionals have called for the revisiting of HIPAA regulations regarding telehealth.¹³ Overall, evidence specific to COVID-19 related cybersecurity is lacking; however, privacy violation and data breach may be an important concern among non-healthcare professional users moving forward.

Finally, the last two negative sentiments identified relate mostly to logistical issues and complaints. These concerns included software or interface malfunctions and problems corresponding with the physician's office, typically requested via fax which Twitter users found inconvenient (compared to electronic sharing). Such concerns have historically been problematic when implementing telehealth, and program or interface reliability is paramount. Moreover, a few people expressed concerns that the telehealth experience seemed impersonal or “weird.” Although many studies suggest high satisfaction among telehealth users, some previous studies have shown that certain telehealth users may have dissatisfaction with the telehealth experience related to personability and the therapeutic alliance.¹⁴ Moving forward, it will be imperative to develop robust telemedicine systems that address technical concerns and platform user experiences before widespread implementation and adoption.

Our study is not without certain limitations. Our search criteria and Tweet selection process may be subject to an element of selection bias, as our key phrases and hashtag queries may not capture and appropriately represent all Tweets related to telehealth. However, we manually reviewed the Tweets obtained to develop representative themes in an attempt to mitigate this concern. Second, we have little information on the users' baseline characteristics whose Tweets were obtained in our search and thus cannot comment on education, socioeconomic status or other demographics. Lastly, the current study only analyzed data from the Twitter platform. We acknowledge there are numerous other platforms that may provide opportunities to deliver telehealth, some of which are utilized at a higher level by a more racially/ethnically diverse population compared to Twitter.⁸ Future research should address these aforementioned limitations.

In conclusion, we found various positive and negative sentiments among non-healthcare professional Twitter users related to telehealth. As widespread telehealth platforms are implemented during the COVID-19 pandemic and beyond, Twitter, as well as other platforms, may provide a novel way of informing healthcare systems and developers to improve their telehealth platforms for users.

Disclosure

Dr. Krittanawong discloses the following relationships – Member of the American College of Cardiology Solution Set Oversight Committee, the American Heart Association Committee of the Council on Genomic and Precision Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Performance Measures, The Lancet Digital Health (Advisory Board), European Heart Journal Digital Health (Editorial board), Journal of the American Heart Association (Editorial board), JACC: Asia (Section Editor), The Journal of Scientific Innovation in Medicine (Associate Editor), and Frontiers in Cardiovascular Medicine (Associate Editor). Dr. Virani discloses the following relationships: Research support: Department of Veterans Affairs, World Heart Federation, Tahir and Jooma Family Honorarium: American College of Cardiology (Associate Editor for Innovations, acc.org).

Central illustration: Summary of individuals’ perceptions and opinions among non-healthcare professionals Tweets regarding telehealth