key: cord-0793488-wpcx3u7y
authors: Kemp, Michael T.; Liesman, Daniel R.; Williams, Aaron M.; Brown, Craig S.; Iancu, Ariella M.; Wakam, Glenn K.; Biesterveld, Ben E.; Alam, Hasan B.
title: Surgery Provider Perceptions on Telehealth Visits During the COVID-19 Pandemic: Room for Improvement
date: 2020-11-13
journal: J Surg Res
DOI: 10.1016/j.jss.2020.11.034
sha: 56a03b9af9c2d922fff6bda3aa5506553b3bce9b
doc_id: 793488
cord_uid: wpcx3u7y

BACKGROUND: COVID-19 has mandated rapid adoption of telehealth for surgical care. However, many surgical providers may be unfamiliar with telehealth. This study evaluates the perspectives of surgical providers practicing telehealth care during COVID-19 to help identify targets for surgical telehealth optimization. MATERIALS AND METHODS: At a single tertiary care center with telehealth capabilities, all department of surgery providers (attending surgeons, residents, fellows, and advanced practice providers) were emailed a voluntary survey focused on telehealth during the pandemic. Descriptive statistics and Mann-Whitney U analyses were performed as appropriate on responses. Text responses were thematically coded to identify key concepts. RESULTS: The completion rate was 41.3% (145/351). Providers reported increased telehealth usage relative to the pandemic (p<0.001). Of respondents, 80% (116/145) had no formal telehealth training. Providers estimated that new patient video visits required less time than traditional visits (p=0.001). Satisfaction was high for several aspects of video visits. Comparatively lower satisfaction scores were reported for the ability to perform physical exams (sensitive and non-sensitive) and to break bad news. The largest barriers to effective video visits were limited physical exams (55.6%; 45/81) and lack of provider or patient internet access/equipment/connection (34.6%; 28/81). Other barriers included ineffective communication and difficulty with fostering rapport. Concerns regarding video-to-telephone visit conversion were loss of physical exam/verbal cues (34.3%; 24/70), less personal interactions (18.6%; 13/70), and reduced efficiency (18.6%; 13/70). CONCLUSIONS: Telehealth remains a new experience for surgical providers despite its expansion. Optimization strategies should target technology barriers and include specialized virtual exam and communication training.

Telehealth is a term that encompasses a wide variety of remote physician and nonphysician health services. 1 In the wake of the COVID-19 pandemic, telehealth has emerged as a strategy to provide care to patients, while complying with the "stay-at-home" orders and the recommendations for "social distancing." 2, 3 The rapid growth of telehealth utilization was aided by efforts to implement and expand telehealth prior to COVID-19. 4 The potential benefits of telehealth have been described previously. These benefits include high patient and provider satisfaction, ability to provide specialized care to areas lacking resources, remote mentorship of health professionals, improved efficiency, and cost savings for patients. 1, [5] [6] [7] [8] [9] [10] Furthermore, we have demonstrated that with appropriate patient selection, postoperative surgical care in a virtual setting has a safety profile that is similar to the traditional (in-person) visit. 11 Prior to the COVID-19 pandemic, telehealth was used in various aspects of surgical care, often dictated by patient and provider preference and comfort with telehealth. As COVID-19 emerged, both providers and patients, regardless of their prior training or comfort with telehealth, have been forced to provide or receive care remotely whenever possible. Sorensen et al. 12 recently conducted a public survey to understand current perceptions on virtual care during the COVID-19 pandemic. The authors identified a high degree of public satisfaction with telehealth visits, but noted that the current elevated preference for virtual care would decrease once socialdistancing guidelines loosen. 12 The ongoing pandemic also offers a unique opportunity to further explore provider perceptions regarding telehealth given that many providers have had few other options to care for surgical patients. Understanding provider perceptions on telehealth in conjunction with patient perceptions will highlight opportunities for improvement and allow for targeted interventions to improve surgical telehealth care.

In this study, we obtained the perspectives of surgical providers in our department regarding various aspects of our telehealth program to understand it's current use and to aid in making sustainable changes for a more effective surgical telehealth program. We hypothesized that many of our surgical providers would be new to offering virtual care, and that their input would identify current limitations in surgical telehealth care.

This study was approved by the University of Michigan Institutional Review Board.

Subject consent was implied by completion of the voluntary survey.

The University of Michigan is 1000-bed tertiary care hospital and high-volume surgical center with inpatient and outpatient surgical services for patients at the primary and associated satellite locations. The department of surgery houses the following subspecialties: acute care surgery, colorectal surgery, endocrine surgery, hepatobiliary surgery, minimally invasive surgery, oral & maxillofacial surgery, pediatric surgery, plastic surgery, surgical oncology, thoracic surgery, transplant surgery, and vascular surgery.

In our department, providers have the option to schedule patients for a telehealth visit. A visit with video assistance is the preferred telehealth modality, however a telephone visit may be J o u r n a l P r e -p r o o f substituted if the patient does not have video capabilities. Remote assistant providers have not been incorporated into our telehealth visits.

All department of surgery attending faculty, advanced practice providers (APPs), fellows, and residents (351 potential respondents) at a single institution were sent a voluntary electronic survey which consisted of 22 questions focusing on telehealth, video visits, and telephone visits (Table A.1) . Prior to distribution, the survey was piloted with a small group of attending surgeons. The survey entailed a combination of question styles including multiple choice, scales, modified-Likert scales (possible selection of "not applicable"), and free text response. Not all questions were required to complete the survey; therefore, a variable number of responses for each question was expected. The survey was open to respondents to complete over a 2-week period (May 5-May 20, 2020).

All data was collected anonymously. Any survey which did not reach greater than 50% completion was removed from subsequent analysis in order to ensure quality. Data was compiled from the completed surveys and descriptive statistics of survey data were calculated when appropriate. In order to identify significant differences between the groups (e.g. estimation of telehealth visits by month, time required for visit completion, etc.), analyses with Mann-Whitney U tests were completed with GraphPad Prism v7 (Graphpad Software, San Diego, Ca). Free-text responses provided in the study were thematically coded based on recurring themes (e.g. physical exam limitations, inefficient workflow, etc.) and involved 3 study team members who J o u r n a l P r e -p r o o f agreed on themes (MK, DL, AW). Frequencies of recurrent themes were then calculated for quantitative presentation.

41.3% of potential respondents (145/351) took the survey and completed at least 50% of it. More than 75% (110/145) of completed surveys were done by attendings or APPs (Table 1) .

There was a broad representation from each of our department's 12 surgical sections. Of those who completed the survey, 63.4% (92/145) indicated that they were caring for patients via telehealth (Table 1) . Of these 92 respondents caring for patients via telehealth, 95.7% (88/92) were attendings or advanced practice providers. The other 4 respondents were trainees (2 fellows and 2 residents). Furthermore, 80% (116/145) responded that they had no formal telehealth training (Table 1) .

Providers were asked to estimate their relative clinical volume of telehealth visits as a percentage of all of their clinic visits for 3 separate time periods: October-December 2019 (pre-COVID-19), January-March 2020 (early COVID- 19) , and April-May 2020 (peak COVID-19).

Providers indicated significant sequential increases in telehealth clinical volume when compared to the preceding time period (p<0.001) with an estimated several-fold increase in this volume during the peak COVID-19 period (Figure 1 ).

J o u r n a l P r e -p r o o f A majority of these visits were completed either at home or in the provider's office (Table 1) . Additionally, 90.2% (83/92) of providers answered that they used telehealth for return/postoperative visits and 77.2% (71/92) of providers use it for new patient/preoperative visits (Table 1 ). Fewer providers indicated that they used telehealth for interprofessional discussions, delivering diagnoses or diagnostic findings, and collaboration with providers at other sites (Table 1) .

When asked about the equipment used, 68.4% (63/92) of respondents indicated that their employer provided at least some type of necessary equipment for a telehealth visit ( Figure 

Providers were surveyed on their satisfaction with various aspects of video visits ( Figure   2 ). Median values with interquartile ranges (IQR) are presented ( Figure 2 ). Most providers reported that they were either extremely satisfied or somewhat satisfied with the following aspects of video visits: video visits in general (76.5%; 65/85), their ability to use the technology platform (83.7%; 72/86), and their ability to elicit the necessary health history (84.9%; 73/86).

Most providers indicated that they were somewhat satisfied with their ability to develop a plan 

Providers were asked to elaborate on the largest barriers to effective video visits. After identifying recurrent themes for quantitative analysis, several barriers were noted. More than half of providers who answered the question (55.6%; 45/81) indicated that the limitations associated with the physical exam was a large barrier ( Figure 4 ). Another frequently reported barrier was either provider or patient lack of internet access, appropriate equipment, or quality connection (34.6%; 28/81; Figure 4 ). Providers also mentioned that a lack of appropriate technology J o u r n a l P r e -p r o o f education or platform familiarity (17.3%; 14/81) as well as other technology issues (3.7%; 3/81) were barriers to effective video visits ( Figure 4 ). Other important themes highlighted communication and the physician-patient relationship as several providers described ineffective communication issues and difficulty with fostering rapport in a video setting. (Figure 4 ). Finally, others highlighted inefficient workflows and lack of administrative support or increased administrative burden as contributing factors to less effective video-based care ( Figure 4 ).

Providers were asked about the frequency in which they experience technical difficulties and how often these technical difficulties resulted in the need to convert from a video to telephone visit. Based on a Likert-scale (Table A. 1), a majority of providers (72.7%; 64/88) indicated that they experience a technical difficulty sometimes. A majority of providers (75%; 66/88) also reported that these technical difficulties require conversion to phone visit sometimes.

When asked to elaborate on the effects that converting to a phone visit has on the patient encounter, additional recurring themes were identified amongst these responses (n=70; Figure   A .2). Approximately 25% (18/70) of providers suggested that conversion to a phone visit had no effect ( Figure 

During the COVID-19 pandemic, adoption of telehealth has increased substantially and abruptly. 2, 3, 13 Our department of surgery has observed increases in its use as a means to continue providing care. Importantly, this study was conducted in a pandemic context in which providers seemingly had fewer options available for outpatient care and our institution pivoted toward telehealth care as much as possible. Therefore, this study highlights the perspectives of providers who were forced to use telehealth to some extent independent of their prior experience and bias.

In fact, the data presented in this study indicates that a majority of providers have little to no experience with providing care in a virtual setting or any formal training in telehealth. This may be a phenomenon of our rapid institutional expansion and highlights that other institutions may need to conduct similar assessments of their own staff and create formalized telehealth curricula for providers.

Our study found many providers are conducting these visits in their own home and with their own personal devices. Some of these responses may be related to the context of the pandemic, however due to this survey, our group will be evaluating why smartphones were a preferred modality for conducting these telehealth visits at the time of this survey. Regardless, training for telehealth providers should emphasize principles of privacy and compliance with the Health Insurance Portability and Accountability Act (HIPAA) in a virtual setting. For example, patient privacy and information security in telemedicine has been previously described as an area of concern. 14 Due to the massive increase in virtual care seen during COVID-19, it may be worth considering offering providers standardized institutional equipment in order to provide such care in a secure fashion. Not only could institutional equipment reduce the cost burden on providers J o u r n a l P r e -p r o o f in terms of data plans, but it would also guarantee that the device used is properly encrypted. Additionally, standardized equipment could limit any effect that variable provider software has on the remote care experience.

Institutional attention to technology should also consider addressing and anticipating technology-based barriers to virtual care. Several providers indicated that patient or provider access to internet, equipment, or an appropriate connection was a large barrier to delivering effective care. Additionally, these technological issues would, at least sometimes, lead to converting the video visit to a phone visit. Some indicated this further decreased the visit's efficacy. Furthermore, providers also referenced that patient lack of technological knowledge or platform familiarity inhibited care. While evaluating use of telehealth care via their institution's online portal system, Kummerow Broman et al. 15 found that, although infrequent, some patients were unable to participate in this care due to technical difficulties. Similarly, a prior retrospective analysis from our group on barriers associated with failed-completion of telehealth visits suggested that some patients encounter technical issues and subsequently fail to complete their telehealth visits. 16 Considering our data within the context of this literature, anticipating and addressing any technology-based barriers is clearly an important aspect to optimizing telehealth programs. 15, 16 Importantly, given that millions of Americans do not have access to broadband internet, providers need to be well-versed in their own institutional and patient population-based trends with regard to access to internet or technology. 17 This will better prepare and even prime providers to appropriately survey patients on their available internet access and necessary equipment prior to scheduling them for telehealth visits. Certainly, patients who do not have the appropriate equipment or broadband connection would benefit from being seen in person, especially if a phone visit will not suffice. With respect to lack of technological knowledge or J o u r n a l P r e -p r o o f platform familiarity, it is possible that these issues may actually be related to the failings in the design of the telehealth delivery system. Therefore, when making improvements, institutions should also obtain patient input regarding how to improve their telehealth experience.

Understanding surgical provider satisfaction with virtual visits is necessary for the identification of areas for improvement. Based on the data, provider satisfaction for various aspects of video care were variable. Importantly, only one survey question pertained to the actual use of our institution's video visit platform while the other aspects were more descriptive of video visits as a whole, independent of the actual technology or software used. Here, a majority of providers reported high satisfaction with video visits in general, their ability to use the platform, and their ability to elicit the necessary history. However, a greater proportion of reduced satisfaction scores were reported for other aspects of the video visit, including the ability to perform physical exams of sensitive and non-sensitive areas. These perspectives were further reflected in the free text responses offered by providers when asked for their opinion on the largest barriers to effective care in video visits. For example, more than half of providers mentioned limitations related to the physical exam. Interestingly, Endean et al. 6 reported high provider confidence in telemedicine vascular physical exams, although these providers had onsite physician assistants to obtain blood pressure and doppler probe vascular signals. These onsite providers are not part of our video clinics and could explain provider concerns regarding the virtual exam and the relatively lower satisfaction scores for sensitive and non-sensitive exams. This further highlights the need for targeted education in this area of virtual exam techniques. A training program focused on virtual exam techniques that can be completed with or without an onsite assistant could prove beneficial to telehealth providers in order to increase the effectiveness of their visits, even outside the context of the pandemic. 18, 19 J o u r n a l P r e -p r o o f Other providers in this study highlighted concerns regarding difficulty with establishing rapport or barriers to effective communication during video visits. This could be why the satisfaction scores, as compared to some other aspects of video care, were lower for the ability to share bad news. In contrast to our findings, Agha et al. 20 randomized patients to receive either virtual or in-person care; they found similar patient satisfaction scores regarding patient-centered communication and the ability to develop rapport. The program in this particular study, however, incorporated an onsite nurse as an assistant; therefore, it is unclear how these results apply in the COVID-19 context when it is presumed that onsite assistants were not available for a majority of these visits throughout the country. 20 Nevertheless, in line with the data related to virtual exams, these results further highlight the need for dedicated virtual training for telehealth providers that extends beyond trial and error. For example, training on principles of effective virtual communication may improve a surgical provider's ability to connect with patients (i.e. enunciation, eye-contact, minimizing body gestures, etc.). 19 Previously, it has been suggested that telehealth can be an efficient way to provide care. 7, 9, 10 We investigated the provider-estimated time spent on video visits for new patient and return visits, which are the two highest reported uses of telehealth in our institution's surgical practice. Interestingly, providers in our study estimated that, when excluding documentation, they save only 5 minutes with a new patient video visit as compared to a new patient traditional visit. In contrast, no difference in length of visit was appreciated for return patient visits between the two groups. Furthermore, a number of providers actually reported video visit concerns related to workflow inefficiencies and increased administrative burden or lack of administrative support. Considered together, if the estimated 5 minutes saved for new patient visits in a video setting is real, this is likely lost with the associated workflow inefficiencies and other contributing burdens. Additionally, as few trainees indicated that they were seeing patients in a telehealth setting, it is also conceivable that this difference will dissolve as trainees become better integrated into telehealth care and as attendings devote time to teaching their trainees during these encounters. Regardless, this study highlights that attempts should be made to optimize workflow by incorporating some administrative support (medical assistants, nursing, etc.). Furthermore, it is possible that this will have a positive impact on the cost-effectiveness of these clinics as providers will gain additional time to see more patients.

This study has several limitations. First, this study involved a single institution and department, making generalizability difficult. However, the institution represents one that was dramatically impacted by COVID-19 and essentially halted all unnecessary in-person clinic visits in favor of telehealth visits. Future studies may consider larger sample sizes across multiple institutions and provider types. Another limitation is that trainees represented a minority of those caring for patients in a telehealth setting. As telehealth care becomes further emphasized in training and as the acuity of the pandemic subsides, trainee perspectives and the effects that trainee involvement has on efficiency should be reevaluated. Additionally, we did not include cardiac, otolaryngology, urology, or neurosurgery as they are not considered part of our department of surgery. It is therefore unclear how this data applies to those specialties or even non-surgical specialties. Another limitation is that there may be some inherent selection bias in our results as providers who either like or dislike telehealth may have been more or less likely to take the survey. Another limitation is we do not specifically assess the effects that remote care has on documentation practices and efficiency. Future studies should assess for possible effects.

Lastly, our survey highlights perspectives on telehealth during the pandemic when there were several institutional changes occurring and providers had fewer options for outpatient care.

Therefore, it is unclear if these perspectives will change as experience is gained or as the acuity of the pandemic subsides. These perspectives, including what is acceptable or unacceptable for telehealth care, should be reevaluated outside of the pandemic context.

Providing surgical care via telehealth significantly expanded during the COVID-19 pandemic and is a new experience for many providers. Although the patient's perspective on telehealth has been described within the context of this pandemic, here we offer the provider perspective. 12 Understanding opinions on telehealth in the current environment is vital to improving telehealth programs. The pitfalls and barriers to effective implementation of telehealth that we have described from the provider perspective can improve existing telehealth programs and streamline their adoption.

Declaration of Interest/Disclosure Statement: All authors do not have any disclosures or conflicts of interest to report.

Submission Declaration: The work described has not been published and it is not under consideration for publication elsewhere. The publication is approved by all authors Authorship Statement: All authors contributed substantially to the concept and design of this work; or acquisition, analysis, or interpretation of data. All authors contributed substantially to the drafting or critical revision of this work. All authors have approved this final version for publication and agree to be accountable for all aspects of the work. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content.

The author received no financial support for the research, authorship, and/or publication of this article. Median values with interquartile ranges are presented. Providers reported the highest degrees of satisfaction for the following aspects of video clinic visits: overall general ability to use the platform, and ability to elicit necessary history. Providers reported most often that they were somewhat satisfied with their ability to develop a plan. Comparatively, providers were less satisfied with their ability to break bad news to patients. The lowest satisfaction scores were reported for the ability to perform non-sensitive exams and the ability to perform sensitive exams. Approximately 70% (63/92) of telehealth providers use equipment provided by their employer while others indicated use of personal equipment. Smartphones were the highest reported equipment used by providers, although no providers reported that these were provided by their employer. For all other equipment types, there were appreciated differences between reports regarding technology equipment that is used by providers and that which is provided by the employer. 

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