key: cord-0807275-3upn2995
authors: Malouff, Timothy D.; TerKonda, Sarvam P.; Knight, Dacre; Abu Dabrh, Abd Moain; Perlman, Adam I.; Munipalli, Bala; Dudenkov, Daniel V.; Heckman, Michael G.; White, Launia J.; Wert, Katey M.; Pascual, Jorge M.; Rivera, Fernando A.; Shoaei, Michelle M.; Leak, Michelle A.; Harrell, Anna C.; Trifiletti, Daniel M.; Buskirk, Steven J.
title: Physician Satisfaction with Telemedicine during the COVID-19 Pandemic: The Mayo Clinic Florida Experience
date: 2021-07-01
journal: Mayo Clin Proc Innov Qual Outcomes
DOI: 10.1016/j.mayocpiqo.2021.06.006
sha: 483c5d330b0d2cbed4dd9f239cfae424e6bb370e
doc_id: 807275
cord_uid: 3upn2995

Objective To evaluate physician perceptions and attitudes toward telemedicine use at a tertiary care academic institution in Northeast Florida during the COVID-19 pandemic. Methods An anonymous 38-question cross-sectional survey was developed using Qualtrics and emailed to all staff physicians from all specialty disciplines at the Mayo Clinic Florida. The survey was open from August 17, 2020 through September 1, 2020. Collected data included general demographics and employment information, attitude and experience with telemedicine use before and during COVID-19, perception of patients’ experience, and the effect of telemedicine on burnout. Results The survey was distributed to 529 eligible physicians at our institution, with 103 physicians responding (19.5%). The distribution of specialties was 22.3% primary care specialties, 40.8% other internal medicine subspecialties, and 17.5% surgical specialties. Collectively, 63% found comparable quality of care when provided virtually (vs. in-person), while 80% perceived telemedicine as cost-effective. A total of 76% of physicians felt that telemedicine increased flexibility and control over patient-care activities, with 36% reporting improved work-life balance and 30% reporting improved burnout symptoms. Overall, 42% preferred using telemedicine over in-person visits when possible. Conclusions Physicians generally held positive attitudes regarding the adoption of telemedicine, and perceived that the quality of healthcare delivery as generally comparable to in-person care. Future studies are needed to explore attitudes regarding telemedicine after the pandemic, and how this virtual technology may be further utilized to improve physicians’ professional and personal well-being.

Telemedicine includes the use of telecommunication technology to provide healthcare remotely 1 . In 2020, the recent COVID-19 pandemic had various implications on healthcare delivery. This resulted in a need to adjust and provide quality care to patients while limiting potential exposure to the virus, for both, patients and healthcare professionals 2, 3 . During the pandemic, physicians have utilized videoconferencing or virtual communication software, video visits, telephone visits, and electronic written visits or e-consults, with the potential advantages of providing comparable quality care while social distancing 2, 3 . Due to the pandemic, telemedicine has seen exponential growth and widespread adoption 4 , consisting of over 90% of visits in some clinics 5, 6 . Telemedicine has been used in almost every specialty, including procedural specialties 5, 7-17 . Further, especially since the start of the COVID-19 pandemic, telemedicine use has increased internationally 18-21 .

Although various forms of telemedicine, including phone calls and electronic messaging, have been used extensively in our clinic for years, the COVID-19 pandemic has led to the implementation and successful use of audio-visual technologies for patient care visits across the Mayo Clinic Enterprise. These visits occur via commonly-used commercial software, as these platforms are secure, HIPAA compliant, and accessible to the general public.

Previous limited evidence showed telemedicine to provide a generally effective, comparable and satisfactory quality of care, and sometimes with better clinical outcomes for certain conditions 22 ; however, there is a paucity of larger studies regarding perception and attitude regarding patientphysician interactions, satisfaction with services, and the ease and comfort of using telemedicine, preference for face-to-face communication, technology infrastructure support, and insurance coverage 23 , especially among providers with limited experience using telemedicine technology prior to the COVID-19 pandemic. Reports from our institution reporting on patients treated virtually for possible J o u r n a l P r e -p r o o f and confirmed COVID-19 suggest that patients recognize telemedicine as a key component of receiving health care throughout the pandemic 24, 25 .

Further, few studies have analyzed if provider well-being and burnout are impacted by the adoption of telemedicine, as telemedicine theoretically provides more flexibility in terms of physician time and geographical location while performing virtual visits 5 . Up to the onset of the pandemic, Hartzband et al pointed out medicine had been at a crisis point regarding burnout 26 . Increased flexibility from telemedicine supporting provider autonomy may enhance the experience of intrinsic motivation that staves off "amotivation" and burnout. Given this, we aim to address these gaps in the literature, and provide insight into physician perceptions of telemedicine at the Mayo Clinic in Florida.

This study included conducting a 38-question of five-domain anonymous survey that was developed through expert panel consensus informed by certain elements from existing evidence and models, including the unified theory of acceptance and use of technology (UTAUT) 27 , Technology Acceptance Model 2 (TAM2) 28 , and Diffusion of Innovations frameworks 29, 30 . The survey was conducted using Qualtrics survey software (Qualtrics, Provo, Utah). A list of all Staff Physicians at the Mayo Clinic in Jacksonville, Florida as of August 2020 was obtained. The survey was distributed via email to all Staff Physicians. Anonymous links and QR codes were sent to all physicians. All specialties were included; however, traditional non-clinical specialties including diagnostic radiology, pathology, and non-clinical physician research were excluded from the survey to minimize outliers and positive skewing. The survey remained open for two weeks from August 17, 2020 to September 1, 2020, and results were collected in Qualtrics. Participation was optional and voluntary. Our study was deemed exempt by our Institutional Review Board. For the purposes of our study, telemedicine was defined as the use of commercially available audio-visual software programs for videoconferencing with patients for scheduled J o u r n a l P r e -p r o o f consultations or return visits. Other commonly used forms of telemedicine, such as e-consultations or phone calls, were excluded given the widespread use of these prior to COVID-19.The survey included general demographic and professional information as well as five distinctive domains: 1) overall experience with telemedicine use before and during COVID-19, 2) future adaptability to using telemedicine; 3) perception about patients' experience, 4) and the effect of telemedicine on burnout;

and 5) narrative reflections and accounts of experience about barriers of facilitators to using Descriptive statistics were performed for all questions. Comparisons of the five specific domains of interest ("I am open to using telemedicine routinely in the future for consultations," "I am open to using telemedicine routinely in the future for return visits," "Assuming both are equally appropriate, I prefer to use telemedicine over face-to-face visits," "What role has telemedicine played in your experience of burnout," and "Overall, my work-life balance has been improved with telemedicine") were made using a Wilcoxon rank sum test (current position), Spearman's test of correlation (years of practice following residency and age), or a Kruskal-Wallis rank sum test (specialty). p-values of <0.05 were considered as J o u r n a l P r e -p r o o f statistically significant. All statistical tests were two-sided. Statistical analyses were performed using SAS (version 9.4; SAS Institute, Inc., Cary, North Carolina).

The survey was distributed to 529 physicians at our institution, with a total of 115 physicians providing responses to the survey. There were 12 incomplete survey responses or surveys that were submitted in error, leaving 103 responses for analysis. Thus, the response rate was approximately 19.5% of physicians in eligible specialties.

Approximately 78% of physicians were Consultants, indicating that they have worked within the institution for at least 3 years. Of the 103 respondents, 22.3% were in primary care specialties, 40.8% were in internal medicine subspecialties, and 17.5% were in surgery or surgical subspecialties. Years in practice following residency were fairly evenly distributed from under 5 to over 30. Before COVID-19 pandemic, 71.8% of physicians had not used telemedicine before. A summary of physician characteristics and previous experiences with telemedicine is provided in Table 1. A summary of responses for each question of the survey are reported in Table 2 . Specifically, approximately 63% of respondents agreed or strongly agreed that the quality of care delivered using telemedicine was comparable to face-to-face visits, and approximately 80% of respondents either agreed or strongly agreed that telemedicine is a cost-effective way for delivering healthcare.

Approximately 76% of physicians felt that telemedicine has increased flexibility and control over how the physician performs patient-care activities.

Overall, physicians feel that they have adequate technological support and feel skilled at using telemedicine, with 87% of respondents feeling skilled at using telemedicine, and 55% agreeing that patients find telemedicine easy to use.

Physicians also feel that patients like telemedicine visits. Approximately 51% of physicians agree that patients find quality of care with telemedicine to be comparable to the quality of care during a face-toface visit, and 73% agree that patients are at ease with communicating over telemedicine.

In regards to burnout, approximately 30% of respondents felt that telemedicine alleviated symptoms of burnout, and 36% agreed that work-life balance has improved with the use of telemedicine (Table 3) .

Primary care physicians were statistically more likely to have burnout symptoms alleviated by telemedicine (p=0.006) and improve work-life balance (p<0.001) with telemedicine, compared to internal medicine subspecialties, surgeries, or other specialties (Supplemental Tables 2-5 ). There were no significant differences for these questions when comparing position (p=0.61 and p=0.62, respectively), years in practice (p=0.69 and p=0.38, respectively), or age (p=0.51 and p=0.28, respectively).

There was no difference between Consultants and Senior Associate Consultants (p=0.50), years in practice (p=0.28), younger or older physicians (p=0.56) or specialty group (p=0.14) for openness to using telemedicine in the future for consultations. Similarly, there were no statistically significant differences among the same groups for telemedicine use for return visits (p=0.9, p=0.19, p=0.39, p=0.058, respectively).

Overall, 68% of physicians are open to using telemedicine in the future for consultations and 88% of physicians are open to using telemedicine routinely in the future for follow-up visits or appointments.

Assuming all other factors are equal and there is no detriment to patient care, approximately 42% of physicians prefer to use telemedicine over face-to-face visits, with 22% of physicians reporting neutral feelings.

Our data suggest that physicians have adapted to the implementation of telemedicine technology for clinical consultations and follow ups. In our study, the vast majority of respondent physicians felt skilled at using the technology. Interestingly, almost all physicians were open to using telemedicine routinely for follow-up visits after the resolution of the pandemic, with just under half of respondents preferring telemedicine over face-to-face visits. The findings from this work are similar to other previously reported data regarding adoption of telemedicine use. The generally favorable reviews of telemedicine and physician willingness to adapt the technology is likely secondary to multiple reasons, including cost-effectiveness of care, time-savings to both the physician and patients, and increased flexibility of scheduling telemedicine visits, which may all contribute to improved physician quality of life. Additionally, our results suggest that telemedicine is associated with decreased cost and more time savings for patients, especially those who are required to travel for care. This is necessarily balanced against concerns regarding quality of care and the lack of physical examination inherent of video consultations, although physicians in our study largely feel that the quality of care is similar.

Perceived cost-effectiveness of telemedicine compared to traditional in-person care is one of the primary reasons cited for the positive attitudes toward telemedicine, with 80% of physicians agreeing that telemedicine is a cost-effective way to deliver care. To quantify this, a study by Demaerschalk et al.

evaluating postoperative visit costs found that patients who used video telemedicine services saved an average of $888 per return visit, increasing to $1,501 when accounting for travel and accommodations.

The authors report a savings of $256 per visit even for those patients who did not need J o u r n a l P r e -p r o o f accommodations 32 . Furthermore, a study from the pediatric Cardiology Service at Coimbra University Hospital Center analyzed telemedicine use in Portugal since 1998, and estimated that approximately 1.1 million euros (approximately $1.3 million) in the health system, and approximately 419 euros (approximately $500) per patient, have been saved since adopting telemedicine 20 .

Additionally, there is also substantial time savings for both physicians and patients with the adoption of telemedicine, with approximately 75% of respondents agreeing that telemedicine use has improved flexibility. For physicians, the perceived improvement in flexibility is likely multi-faceted, but most likely due to time-savings and flexibility with scheduling. First, telemedicine visits can be performed anywhere, such as in the office setting or a secure home setting, which may afford greater flexibility for physicians who may be balancing increasing demands both at work and at home, especially during the pandemic.

Additionally, video visits may be easier to reschedule as opposed to in-person visits, where patients frequently travel and have limited flexibility to reschedule. Third, video consultations and returns may limit some of time-consuming logistics of clinic, such as waiting to room or check in patients or walking from clinic room to clinic room. Regardless, more research is needed to quantify the time savings and identify the factors that contribute.

Time savings is also seen with patients, where Chaudhry et al., in a meta-analysis analyzing patients receiving either telemedicine or in-person visits for orthopedic care, found that telemedicine improved time savings for patients, both when including travel time (180 minutes) and excluding travel time (17 minutes) 8 .

Despite the benefits many providers experienced with telemedicine implementation, approximately one-third of physicians surveyed do not believe that telemedicine is comparable to face-to-face visits.

One of the leading concerns is regarding to the potential disparities in quality of care for telemedicine as compared to in-person visits. Although telemedicine can be largely cost-effective and saves time, this J o u r n a l P r e -p r o o f comes at a cost of losing the ability to perform an adequate physical exam, something that is vital to practice and adequate care of patients. Additionally, the physician-patient relationship is largely reliant on personal communications, such as "small-talk," which is largely eliminated when using telemedicine software. As telemedicine is more widely used now than at the time of the study, further survey studies will be vital to understand physician concerns and the relative importance of these concerns.

Perhaps the most often cited concern regarding telemedicine is the feeling of being unable to provide comparable care virtually. Zhang et al. looked at this very question at the Memorial Sloan Kettering Cancer Center during the COVID-19 pandemic. They found that 92% of radiation oncology visits were conducted via telemedicine during the peak of the pandemic. Seventy-one percent of respondents reported that there was no difference in the ability to treat cancer appropriately, with 55% having no difference in overall visit quality 5 .

To support the finding that quality of care is equivalent with telemedicine visits, a study from Stanford's ClickWell Care clinic evaluated ordering patterns for telemedicine visits or in-person visits. Interestingly, there were no differences in laboratory tests ordered, imaging tests ordered, or prescriptions ordered between virtual and in-person visits for 17 of the most common diagnoses, although there were overall more lab and imaging tests ordered following in-person visits for any diagnosis, likely reflecting general medical exams 33 .

Another primary concern with the use of telemedicine is the lack of physical examinations. help compensate for the lack of physical presence during virtual visits, virtual reality has been suggested as a way to enhance the feeling of physical presence during the exam 39 . Additionally, telemedicine can be used preferentially in populations whom have expressed interest in, or particularly benefit from, telemedicine. For example, patients with anxiety and depression tend to prefer telemedicine visits, and have more frequent visits in the virtual setting according to one analysis 33 . Another potential benefit of telemedicine is to improve access to routine and preventative healthcare for underrepresented groups, such as underrepresented minorities or patients in rural communities, who may not be able to cover the expense or time of travel to clinic for routine follow up. Furthering this, telemedicine can also be used to offer clinical trial participation to these underrepresented populations, as intensive follow-up protocols and toxicity management can be performed virtually.

Even though our data suggest that physicians have overall positive perceptions and attitudes regarding telemedicine, our study is not without limitations. First, our study is survey-based, with the typical limitations of survey-based evaluations, including complete responses and a low response rate.

Furthermore, there is a relatively small sample size of some of the subgroups that were examined when making comparisons of survey responses, which results in a lack of sufficient power to detect significant differences. Therefore, the possibility of a type II error (i.e. a false-negative finding) is important to consider. However, using existing evidence, expert opinion and validated frameworks to guide this survey provides strength to its structure that use. Additionally, this work provides a thorough and important representation of physician attitudes and reflections, including the impact of technology on burnout and wellbeing-something that has not been addressed widely before 40 , especially during times of crises like the COVID-19 pandemic.

At approximately the same time as our study, the COVID-19 Healthcare Coalition, of which Mayo Clinic is a participant, surveyed over 1,500 providers regarding the use of telemedicine. In their study, approximately 68% of patients were motivated to increase the use of telemedicine (68% in our study), and 55% found that telemedicine improved satisfaction with work (36% in our study had improved work-life balance) 41-42 . Taken together, our study and the study by the COVID-19 Healthcare Coalition support the notion that telemedicine is an important component of medicine delivery. Additional research is needed to identify if these attitudes persist in the post-COVID-19 clinical environment.

Future research could explore the sustainability of telemedicine, cost benefit of telemedicine, and potential causal relationships between telemedicine and burnout prevention. We acknowledge many patients do not have access to, or knowledge of, the technology required for telemedicine. Further research can investigate methods to improve this healthcare delivery to potentially underserved patients.

This survey analysis found that physicians generally held positive attitudes regarding the adoption for telemedicine, and felt that the quality of care is generally comparable to that delivered in in-person visits. Importantly, a majority of physicians are open to using telemedicine after the pandemic for consultations and routine follow-ups. Additionally, approximately one-third of providers experienced an improved work-life balance or improvement in subjective burnout symptoms with telemedicine. Future studies are needed to explore attitudes regarding telemedicine after the pandemic, and how the technology can be utilized to improve physician well-being. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

Recent advances: Telemedicine