key: cord-0799882-uj9dsu5u
authors: Park, Hyung-Youl; Kwon, Young-Mi; Jun, Ha-Rin; Jung, Seung-Eun; Kwon, Soon-Yong
title: Satisfaction Survey of Patients and Medical Staff for Telephone-Based Telemedicine During Hospital Closing Due to COVID-19 Transmission
date: 2021-07-01
journal: Telemed J E Health
DOI: 10.1089/tmj.2020.0369
sha: 39c601900a3fde5a914be48d308dc927c5d7af5f
doc_id: 799882
cord_uid: uj9dsu5u

Introduction: Telephone-based telemedicine was temporarily permitted in Korea during the COVID-19 pandemic. The purpose of this study was to assess satisfaction with the telemedicine done during temporary hospital closing when in-person visits were not allowed due to in-hospital COVID-19 transmission. Methods: Survey questionnaires partially taken from a telehealth usability questionnaire (TUQ) were sent to 6,840 patients who used telephone-based telemedicine from February 24 to March 7, 2020. Questionnaires sent to patients and additionally created questionnaires to evaluate telemedicine were sent to medical staff (182 doctors and 138 nurses). Results: Response rates of patients and medical staff were 13.2% and 17.2%, respectively. Patients' satisfaction with telemedicine was significantly greater than medical staff's satisfaction for all five components taken from TUQ (all p = 0.000). In addition, created questionnaires showed good reliability, obtaining similar results between doctors and nurses (all p > 0.05). More than 85% of medical staff replied that telemedicine was needed in COVID-19, whereas more than 80% of them worried about incomplete assessment and communication of medical condition. Overall satisfaction with telemedicine by medical staff was 49.7%. The strength of telephone-based telemedicine was patients' convenience (53.4%). However, incomplete assessment of patients' condition (55.0%) was its weakness. Conclusion: Satisfaction with telephone-based telemedicine by patients was significantly greater than that by medical staff (doctors and nurses). Negative views for safety and inconvenience resulted in a greater proportion of dissatisfaction among medical staff. For safe application of telemedicine, medical staff insisted that developing a platform and creating guidelines should be needed.

T he epidemic of 2019 novel coronavirus (severe acute respiratory syndrome coronavirus 2) or COVID-19 has expanded from Wuhan throughout China. It has been exported to a growing number of countries. 1 Six million peoples have been confirmed to be COVID-10 positive and more than 370,000 patients have died from it. 2 With a high transmission rates but no curative therapies or vaccine available, the current management focuses on prevention by social distancing. 3 During the COVID-19 pandemic, health care systems have begun crisis to maintain effective patient care while preventing virus exposure. 4, 5 In this regard, telemedicine takes advantages of continuing to care for patients while isolating high-risk patients to avert further contact. Scheduled office visits are also converted to telemedicine visits in situation when health care workers are quarantined. 6 Although telemedicine has not been readily adopted, widespread implementation has begun during the COVID-19 crisis. 7 In Korea, telemedicine has not been legally allowed by the government. However, consultation and prescription through telephone were temporarily permitted by the Ministry of Health and Welfare from February 24, 2020, due to the COVID-19 pandemic. Telephone-based telemedicine was limited to stable patients to assure safety without emergent medical conditions. The purpose of this study was to assess satisfaction with telemedicine by patients and medical staff during the 17 days of temporary hospital closing when in-person visits were not allowed by the city government fearing mass outbreak.

Two patients were diagnosed with community-acquired pneumonia from COVID-19 in our hospital. After two more patients (one hospital staff responsible for transporting patients and one caregiver) were confirmed to be positive for COVID-19, the city government took measures to temporarily close the entire outpatient clinic and emergency room for 17 days under guidelines set during the 2015 Middle East Respiratory Syndrome (MERS) outbreak. 8 Because in-person visits were not allowed during the temporary hospital closing, 6,840 patients used telephone-based telemedicine from February 24 to March 7, 2020, as an alternative. Survey questionnaires through text messages were sent to 6,840 patients, because all patients had agreed to have personal information collected. Survey questionnaires were also sent to medical staff, including 182 doctors and 138 nurses. All doctors, including traumatologists and radiologists, were included in this survey. This study was approved by our Institutional Review Board (Approval No. PC20QASI0038).

Demographic data such as sex, age, department (medical or surgical), and route to access telemedicine were collected. Questionnaires for patients were taken from the telehealth usability questionnaire (TUQ) with slight changes. TUQ has 21 items in six components (usefulness, ease of use and learnability, interface quality, interaction quality, reliability, satisfaction, and future use). 9 Representative five questionnaire items in four components (ease-of-use, interaction quality, reliability, satisfaction, and future use) were selected to increase response rate and reflect the limit of telephone-based telemedicine. Five items are presented in Table 1 . All items were found to have good (0.7 £ a < 0.9) or excellent (0.9 £ a) reliability based on Cronbach's coefficient alpha. 9,10

Demographic data of telemedicine for medical staff included department (medical or surgical), time spent on each patient, and total calls per day. Same questionnaires taken from the TUQ were also sent to medical staff, including doctors and nurses. 9 In addition, 12 questions in four components (perception, safety, satisfaction, and necessity) of telemedicine were developed and asked ( Table 1) . Strengths and weaknesses of telephone-based telemedicine were asked in forms of openended questions to assess medical staff's opinions. Prerequisites and difficult medical fields to apply telemedicine were also asked.

Categorical variables of the questionnaire were compared using Pearson's chi-square test or Fisher's exact test depending on expected frequency. Cronbach's alpha was calculated to assess the degree of internal consistency and homogeneity among the four components developed in this study. Statistical analyses were conducted using SPSS software (Version 24.0; IBM SPSS Statistics, Armonk, NY) with a level of significance of 0.05.

Demographic data of patients are summarized in Table 2 . Nine hundred six patients (N = 906) responded to the survey among 6,840 patients who used telephone-based telemedicine. The response rate was 13.2%. There were 511 (56.4%) female patients and 381 (42.1%) male patients. More than 50% (52.5%) of patients who used telemedicine were older than 60 years. About 50% (48.7%) of patients used telephone-based telemedicine for medical care, followed by surgical care (34.5%) and unresponded (16.8%). The most common route to telemedicine was through guidance of outpatient clinic nurses (68.9%), followed by attending physicians (13.4%) and media report (7.1%). All patients reported no medical complication from using telemedicine.

Demographic data of medical staff are shown in Table 3 . Fifty-five of 182 doctors and 100 of 138 nurses who had participated in telephone-based telemedicine responded to the survey. The response rate of nurses was significantly higher than that of doctors (72.5% vs. 30.2%, p = 0.000). Departments that medical staff belonged to were similar between doctor and nurse groups. About three-quarters (76.0%) of nurses spent more than 5 min for prescribing telemedicine, whereas 47.3% of doctors spent less than 5 min ( p = 0.011). Almost 90% of doctors reported less than 10 calls per day for telemedicine, whereas 40% of nurses reported greater than 10 calls per day ( p = 0.000). All medical staff reported no medical complication resulting from using the telemedicine.

Results of satisfaction with telemedicine between patients and medical staff are shown in Table 4 and in Figure 1 . Almost 80% of patients reported the convenience of telemedicine, whereas only 38.2% of doctors and 30.0% of nurses replied that telemedicine was convenient to use (both p = 0.000 compared with patients). For interaction quality, 87.1% of patients reported effective expression as in-person visits, whereas less than 10% of doctors and nurses could express themselves effectively ( p = 0.000 for both doctors and nurses compared with patients). Regarding reliability, 87.1% of patients thought telemedicine had the same reliability as inperson visits. However, only 14.5% of doctors and 14.0% of nurses reported that telemedicine had the same reliability ( p = 0.000 both for doctors and nurses compared with patients). Overall satisfaction was reported by 86% of patients, whereas only 52.7% of doctors and 48.0% of nurses were satisfied with telemedicine ( p = 0.000 for both doctors and nurses compared with patients). Finally, 85.1% of patients were willing to use telemedicine service again, whereas only 32.7% of doctors and 37.0% of nurses reported such willingness ( p = 0.000 both for doctors and nurses compared with patients).

The questionnaire developed for medical staff is shown in Table 5 . Cronbach's alpha values for its four components (perception, safety, satisfaction, and necessity) were 0.725, 0.695, 0.752, and 0.714, respectively. These four components had acceptable (0.6 £ a < 0.7) or good (0.7 £ a < 0.9) reliability based on Cronbach's coefficient alpha. 10 Regarding perception, 98.2% of doctors and 98.0% of nurses replied that they knew the purpose, pros, and cons of telemedicine. However, more than 80% of doctors and nurses reported difficulties checking patients' condition, explaining patients' conditions, and obtaining patients' understanding (85.5% vs. 86.0% for checking; 85.5% vs. 83.0% for explaining, and 85.5% vs. 83.0% for patients' understanding). Moreover, 60% of doctors and 70% of nurses reported that an emergent situation could happen because they could not see patients. Regarding satisfaction, 61.8% of doctors and 70.0% of nurses reported the inconvenience of the telemedicine system compared with in-person visits. Regarding overall satisfaction with the telemedicine system, 52.7% of doctors 

Strengths and weaknesses of telephone-based telemedicine based on medical staff's response to open-ended questions 

apply telemedicine were postoperative care including wound dressing (47.7%), followed by symptomatic patients requiring direct examination (31.8%), invasive procedures (4.5%), explanation after further evaluation (4.5%), critically ill patients (4.5%), and dental clinic (4.5%). Prerequisites for application of telemedicine included video telemedicine (40.0%), development of platform (27.5%), limited use under certain conditions (12.5%), voice record for medical dispute (10.0%), interdepartmental cooperation (5.0%), and secure time (5.0%).

COVID-19 has completely changed the paradigm of health care systems. The current dilemma is how to provide service not only for those afflicted with COVID-19 but also for patients suffering from other acute and chronic diseases while protecting medical staff. [11] [12] [13] In this regard, telemedicine must be one of game changers during the COVID-19 pandemic. Although telemedicine has been legally prohibited in Korea, telephone-based telemedicine was temporarily permitted from February 24, 2020, due to the COVID-19 pandemic. After our hospital was temporarily closed on February 21, 6,840 patients used telephone-based telemedicine from February 24 to March 7, 2020. According to the Ministry of Health and Welfare, about 27,000 patients used telemedicine in the whole country from February 24 to April 1, 2020. 14 During early COVID-19, 25.3% of patients used telephone-based telemedicine in a single hospital. Thus, this study was designated to evaluate the advantages and disadvantages of telephonebased telemedicine and suggest a supplementation for safe application of telemedicine based on our early experiences.

In this study, satisfaction with telemedicine by patients was significantly greater than that by medical staff. Although elderly patients older than 60 years counted for half of our subjects, more than 80% of patients replied that telemedicine was convenient, interactive, and reliable. Thus, 86.0% and 85.1% of patients reported overall satisfaction and future use. Similarly, Ló pez et al. 15 have reported that 80% of responders are satisfied with teleconsultation and 63% would use telemedicine again in a telephone survey of patient satisfaction with telemedicine in a rural community. Medical staff also pointed out that strengths of telemedicine were associated with patient's factors including patients' convenience (53.4%), preventing transmission of infection (21.6%), saving time (12.5%), and repeat prescription in emergency (9.1%). This finding was consistent with previous studies reporting that telemedicine was an effective form with benefits such as increased convenience and time saving for patients. 16, 17 Moreover, patients' higher satisfaction with telemedicine might be associated with the emergent situation due to COVID-19. Lewis et al. 17 have reported that patients' great appreciation and satisfaction are due to improved efficiency and cost-effectiveness without the risk of direct person-toperson transmission. More than 98% of medical staff also replied the purpose of telemedicine and 85.8% of them insisted that telemedicine was needed in an emergent situation such as COVID-19. Similarly, Moazzami et al. 18 have demonstrated that telemedicine could provide advantages for medical staff to overcome patient flow and reduce the workload of physicians as well as minimizing the risk of exposure of health care providers to pathogens.

Meanwhile, both doctors and nurses reported significantly lower satisfaction for all questionnaire items compared with patients. Medical staff showed more negative responses to interaction and reliability components. For the questionnaire developed in this study, doctors and nurses were concerned about safety aspects. More than 80% of medical staff reported the difficulty of checking and explaining patients' conditions. Although no medical complication had been noted in this study, 60% of doctors and 70% of nurses were worried about emergent situations that might happen because of limited visualization in telephone-based telemedicine. This result was consistent with a previous study reporting that telephone visits typically conveyed less information, which could be risky compared with video visits, although telephone-based telemedicine was preferred over video visits by providers and/ or patients who were less technologically inclined. 19 Medical staff also reported that weaknesses of telephone-based telemedicine were incomplete assessment of patients' condition (55.0%) and miscommunication (15.0%). Regarding this, Jayawardena et al. 20 have demonstrated that the nature of telemedicine can limit a provider's ability to obtain a comprehensive physical examination, although physical examination is fundamental in physician's diagnostic armamentarium. In addition, medical staff noted that it was difficult to apply telemedicine to postoperative wound care, invasive procedures such as dental clinic, and critically ill patients requiring in-person visits.

However, if such drawbacks are improved and complemented, telemedicine could be helpful for both patients and medical staff because telemedicine also has substantial benefits as mentioned above. First of all, 40% of medical staff insisted that video telemedicine rather than telephone-based telemedicine was needed to check patients' conditions for safe application. Recently, several studies have demonstrated that visual physical examination can be conducted accurately and comprehensively despite inherent weaknesses due to the absence of direct physical contact. 21, 22 Tanaka et al. 22 have reported protocols and methods to maximize the benefit and efficiency of virtual orthopedic examination. Moreover, 27% of medical staff reported the inconvenience for connection with patients and pointed out the need for platform development. Especially, nurses took more time and total calls a day for telemedicine compared with doctors. Khairat et al. 23 have demonstrated that telemedicine platforms can be utilized to improve primary care efficiently by allowing medical staff to follow-up with their patients in a time and place that would be the most convenient for both groups. Voice record and recognition are also needed for telemedicine to be saved as electronic medical records and prevent any medical dispute. For successful development of telemedicine, Yellowlees 24 already emphasized that clinical documentation and further voice-recognition typing systems would remain a crucial part of communications for clinicians using telemedicine in the future. Finally, diseases and medical conditions that can be treated and followed by the telemedicine should be clarified through expert discussion and guidelines. Similarly, repeat prescriptions through telemedicine should be done with routine follow-up in accordance with appropriate guidelines. 25 This study has some limitations. First, patients' satisfaction with telephone-based telemedicine might have been overestimated because in-person visits were not allowed during temporary hospital closing due to in-hospital COVID-19 transmission. Satisfaction by patients may be different when both in-person visits and telemedicine are available. Second, selection bias, including only satisfied patients, might have influenced the results, because the response rate of patients was low (13.2%). Third, the possibility of medical complications should be considered because telephone-based telemedicine was limited to stable patients to assure safety and most patients wanted repeat prescriptions. Finally, satisfaction survey of telemedicine was done in a single universityaffiliated hospital in this study. The medical condition and situation of patients could be different depending on the role and size of clinics and hospitals. Thus, further trials considering different roles of clinics and hospitals are needed to validate and extend the results of this study. Despite these limitations, the strength of this study is that it is the first study to assess satisfaction of telephone-based telemedicine done as an alternative during temporary hospital closing when inperson visits are not allowed.

Response rates of patients and medical staff were 13.2% and 17.2%, respectively. Patients' satisfaction with telephonebased telemedicine was significantly greater than satisfaction by medical staff, including both doctors and nurses. Medical staff reported good perception of the purpose and necessity of telemedicine during the COVID-19 pandemic. However, negative view for safety and inconvenience by medical staff resulted in a greater proportion of dissatisfaction. Patients' convenience was a strength of telemedicine, whereas incomplete assessment of patients' conditions was its weakness. For direct procedures and examination that are only possible in in-person visits, it is difficult to apply telemedicine. For safe application to reduce the potential risk of untact medical care, medical staff insisted that the development of a telemedicine platform including visual displays and voice record was needed. Moreover, diseases and medical conditions that can be followed by telemedicine should be clarified through expert discussion and guidelines.

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Ministry of Health and Welfare. Press release. 2020. Available at www.korea.kr/ common/download.do?fileId=190858709&tblKey=GMN (last accessed

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No competing financial interests exist.