The Patient Perspective on Telemedicine

Short abstract

Content available: Author Audio Recording

Abbreviations

COVID‐19

coronavirus disease 2019

SARS‐CoV‐2

severe acute respiratory syndrome coronavirus 2

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Living with liver disease, especially advanced cirrhosis or a liver transplant, is a time of extreme vulnerability and anxiety for patients whose understanding of and ability to cope with their prognosis comes directly from their medical team’s rapport, knowledge, and patient‐centeredness. There is a familiarity and comfort that comes from an office visit: the smiling face of the frontline staff, the warmth of a handshake, the eye‐to‐eye contact that happens in the examination room. With the rapid adoption of telemedicine during the coronavirus disease 2019 (COVID‐19) pandemic, there has been a shift in patient care, and with it a disruption from the familiarity of and comfort with the office visit, to the use of technology, where one is sitting at home in front of a screen while engaging with their provider. Telemedicine is not new, but COVID‐19 has thrown its use into daily practice with a sense of urgency for which many patients may not be ready. As a survivor of liver disease and a patient advocate, it is especially important for us to ensure that telemedicine is used in such a way as to meet the physical and psychosocial needs of people with liver disease. As we learn from this experience and increase the use of telemedicine, we have new opportunities to extend beyond the in‐person visit and build on and expand partnerships between patient and provider, reduce barriers to provider access, and improve the health of people with liver disease.

Before the COVID‐19 pandemic, telemedicine was not used extensively for a number of reasons ranging from a lack of interest by patients to the fact that reimbursement rates and insurance coverage made it cost‐ineffective for providers. A prepandemic, cross‐sectional study conducted by Reed and colleagues ¹ found that in a sample of 1,131,722, patients attended in‐person office visits far more often than telemedicine visits: 86% of patients chose in‐person visits and only 14% scheduled telemedicine visits, with only 7% of those taking place via video. The COVID‐19 pandemic created a need that rapidly transformed health care delivery. From January to July 2020, online searches for the keyword “telemedicine” surged nationwide. ² Patients wanted to see their trusted provider but were uncertain of how to start the process. Medical relationships were disconnected as both the provider and the patients became dissatisfied as office visits were canceled and routine medical procedures were disrupted because of safety concerns. The fear and anxiety that come with advanced liver disease were heightened and exacerbated by the compounding fear of COVID‐19 infection. The resiliency of patients and providers overcame these disruptions, and both parties adapted to new systems of care.

Overall, telemedicine is well received by people. In a cross‐sectional study of more than 1 million patients conducted in the J.D. Power survey before the COVID‐19 pandemic, telemedicine was associated with good overall patient satisfaction despite barriers, such as seeing their provider via video and limited access to services. ³ That is not to say there were not problems. Of those polled, more than one‐third of patients experienced a problem during the visit, leaving many with some degree of dissatisfaction. Although telemedicine can remove some barriers, such as the need to travel and pay for parking, it introduces others, such as difficulty with access to or knowledge of how to navigate the systems necessary for telehealth. These barriers can be overcome in any number of ways. Examples of assisting patients with telehealth include, but are not limited to, holding an orientation call prior to the telemedicine visit to ensure understanding of the cost, payment, and how services will be provided.

The J.D. Power survey also found that although patient satisfaction scores were high among those with excellent health, those with the lower self‐reported health were less satisfied. Factors contributing to this lower degree of satisfaction included chronic conditions, life‐threatening illness, and inability to fully comprehend information during visits. These three factors certainly apply to people living with liver disease. Additional factors may include an inability to monitor vital signs or access to a patient portal to discuss symptoms with their provider outside the visit. There may be a feeling of powerlessness, ranging from the inability to simply schedule an appointment or accurately describe their symptoms to worrying that their provider might require an in‐person visit that could expose them to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Thus, the trend to an increased use of telemedicine requires patients and providers to adopt new ways of communicating.

As the COVID‐19 pandemic raged, medical providers judiciously weighed the pros and cons of accelerating the use of telehepatology, or telemedicine for advanced liver disease, in an effort to quickly change their practice’s workflow to improve patient care and maintain safety for both staff and patient. ⁴ With little time, and under high‐stress conditions, medical staff pivoted to meet the demands placed on them to provide patient care in both rural and urban settings. Despite a lack of experience in telemedicine and the high volume of telemedicine visits, high patient satisfaction fortunately remained unchanged. In fact, video visits were associated with greater patient satisfaction when compared with in‐person visits. ⁵ Even when restrictions were being lifted, 31% of all patients surveyed said that their last medical visit was virtual. ⁶ The many benefits of telemedicine that contribute to patient satisfaction include timely appointments, seeing a familiar physician’s face (albeit via video), quick access to medication refills, visits from home with no need for travel, and avoiding the risk for exposure to SARS‐CoV‐2 (Fig. 1).

FIG 1.

Top four benefits of telemedicine. ⁷

Building familiarity and trust still drives patient satisfaction in all areas of health care, whether in person or via telemedicine. At‐risk underrepresented minorities and first‐time patient visits may require even more interaction with medical staff and the physician. ⁷ Research has shown that when working with vulnerable populations, including people who use drugs and/or those in opioid treatment programs, it is especially important to establish trust and ensure confidence in the technology as it relates to privacy and security. Without them the provider–patient relationship suffers because the patient may not feel comfortable discussing sensitive and illegal topics, such as substance use. ⁸ Of equal importance is ensuring that telemedicine does not exacerbate racial and sociodemographic disparities among non‐Hispanic Black, older, or uninsured populations. ⁹ As patients and physicians adopt the new telemedicine trend, the digitalization of health care can continue to thrive and meet the needs of our changing society, but it also must be inclusive and not leave people further behind.

In a year marked by changes to the way that medical treatment is offered, paid for, and conducted, preliminary studies show that most patients are highly satisfied with telemedicine. There are still opportunities to improve patient satisfaction in many areas (Fig. 2). Facilitating access to required technology, easing payment concerns, and scheduling preappointment conversations with office staff are good starting places for enhancing the patient experience with telemedicine. Prior to the COVID‐19 pandemic, patients and physicians had little experience with telemedicine. The urgency to obtain medical care during the COVID‐19 pandemic forced patients and doctors to adopt telemedicine as a new modality of care. Telemedicine can still offer personalized care in a manner that fulfills the patient’s need for physical safety and trust. As a result, telehealth is not a passing phenomenon but is hopefully here to stay.

FIG 2.

Patient satisfaction with telemedicine.