key: cord-1012463-iohwy6gj
authors: Dobrusin, Avi; Hawa, Fadi; Gladshteyn, Mark; Corsello, Paul; Harlen, Kevin; Walsh, Charlie; Alaparthi, Latha; Weinstein, Michael; Baig, Nadeem; Sousa, Andrew; Gunaratnam, Naresh T.
title: Gastroenterologists and Patients Report High Satisfaction Rates with Telehealth Services during the Novel Coronavirus 2019 (COVID-19) Pandemic
date: 2020-07-11
journal: Clin Gastroenterol Hepatol
DOI: 10.1016/j.cgh.2020.07.014
sha: 3b5076932df9e6f8689a61a37f5013025dab757d
doc_id: 1012463
cord_uid: iohwy6gj

nan

On March 11, 2020 , the World Health Organization declared the novel Coronavirus disease to be a global pandemic with millions affected and hundreds of thousands of deaths.

Numerous restrictions have been enacted to mitigate disease transmission and ensure that the healthcare system has the ability to effectively respond to increased patient volume and acuity. 3 In part, this has included the cancellation of many elective ambulatory clinic visits with the implementation of telehealth modalities in their place. 4 To further encourage the use of telehealth, the Centers for Medicare and Medicaid Services (CMS) increased payments for these encounters and permitted the use of audio-only technology. 5 Telehealth, here used interchangeably with the term telemedicine, has been defined as the use of telecommunication modalities, such as telephone and real-time video, to connect patients with clinicians for the purpose of providing healthcare. 6 Patients and providers alike report high levels of satisfaction with telehealth encounters, due to its convenience and lower cost, and view the quality of care as comparable to traditional office visits . [8] [9] [10] Among the benefits of telehealth are improved outcomes, increased efficiency, and ease of use. 11, 12 Telehealth may also increase access to care by decreasing travel time and cost, limiting missed work days, and reducing the need to find alternative caregivers, especially among rural communities. 8, [11] [12] [13] [14] During disasters, such as the COVID-19 pandemic, access to healthcare may be similarly limited for an even greater number of patients and telehealth has been proposed as a useful and necessary modality in overcoming this challenge. 15, 16 Despite this, there have been limited studies on patient and provider experience with telehealth services when they are used during disasters or other disruptions in the healthcare system . 17 We determined the impact of the sudden increase in telehealth usage during the COVID-19 pandemic on patient and provider satisfaction within community-based gastroenterology (GI) practices.

We conducted a survey of GI patients' and physicians' satisfaction with telehealth during the COVID-19 pandemic. A total of 13,084 patients from two community-based GI practices in Michigan and the Washington, DC region who participated in a telehealth visit from March-May of 2020 were sent an online satisfaction survey by email. Responses were received from 1,492 patients as of June 17, 2020 date. The survey consisted of two prompts: "My GI provider was able to address my concerns during the telehealth visit," and "I am willing to have more telehealth visits in the future." Responses were recorded on a five-point Likert scale (strongly agree, agree, neutral, disagree, or strongly disagree). Patients were also queried on type of technology platform used with the following response options: smart phone/tablet, laptop/desktop, phone (audio-only), or other. Sex, age group, and visit reason were also collected.

Concurrently, a provider-based opinion survey was distributed to a medical association consisting of ninety-five independent GI practices with 2200 providers in thirty-eight states who are members of the Digestive Health Physicians Association (DHPA). 18 Seventy-one practices with 2,017 providers opted to participate in the survey (74.7% practice response rate). Responses were received from 503 of these providers (22.9% overall response rate). The survey consisted of four prompts about telehealth services:

(1) "Telemedicine is an acceptable care delivery model for a segment of GI patients," (2) "Telemedicine allows me to get an accurate health history for my patients and formulate a satisfactory care plan," (3)

"Telemedicine allows me to provide timely testing and follow-through without interruption to patient care," and (4) "I will continue using telemedicine in my practice to deliver patient care." Responses were recorded on a five-point Likert scale of strongly agree, agree, neutral, disagree, or strongly disagree.

Providers were also asked to project what percentage of their future care would be delivered via telehealth: 0-25%, 26-50%, 51-75%, or 76-100%. The ninety-five practices in DHPA were asked to provide the number of telehealth visits conducted by all providers in the DHPA member medical group practices each month during a three-month period from March-May, 2020. Responses to this inquiry were received from thirty-seven practices.

High satisfaction for all groups was defined as ≥80% of approval (response of strongly agree and agree) to individual survey components. This threshold was selected based on customer satisfaction benchmarks for the telecommunication and healthcare sectors from the American Customer Service Index. 19 Patient satisfaction was examined by age and reason for visit.

Patient characteristics for the 1,492 respondents are shown in Appendix Table A Overall, patients were highly satisfied with their telehealth visits; with greater than 80% indicating that the provider addressed their concern and that they were willing to participate in telehealth visits in the future. High satisfaction was observed in all age groups, with the highest rates in patients over age 85 (Figure 1a) . Similarly, the vast majority of visit reasons were associated with high patient satisfaction (Appendix Figure A-1) . Among the 86.4% of patients seen for hepatic, biliary, and pancreatic disorders that felt that the provider addressed their concern, 77.3% were willing to engage in a telehealth appointment in the future.

Practices were geographically diverse and ranged in size from six to 170 providers. Overall, we found a high level of satisfaction with telehealth services among providers, with greater than 90% of respondents approving (strongly agree or agree) of all four prompts (Figure 1b) . The majority (54.1%) expected that less than one-quarter of their future care would be delivered via telehealth, with 10.7%

projecting it to make up over one-half of future encounters (Appendix Figure A-2) .

Telehealth visit volume data was obtained from thirty-seven practices with a total of 899 providers. Collectively, these practice groups performed 51,187 telehealth visits in March, 90,084 in April, and 81,885 in May, 2020.

In 2008, three distinct aims were proposed in an attempt to improve the healthcare system in the United States: (1) improving the care experience, (2) reducing cost, and (3) improving patient and population health outcomes. 20 When viewed through the lens of these goals, telehealth is an effective care delivery modality and the results of this survey suggest that its expanded use would lead to system improvement. First, our findings show a high level of overall patient and provider satisfaction following telehealth appointments. Both groups perceived it to be an effective way to deliver gastroenterological care and expressed a willingness to participate in similar visits in the future. This is despite the abrupt nature of the transition to virtual visits, with little opportunity for practices to optimize processes and correct technology problems. In addition, patients had no option other than virtual visits due to the pandemic and, nonetheless, were highly satisfied with it and open to incorporating it into their care. It is reasonable to expect that patient and provider satisfaction would further increase when telehealth is implemented in a more stepwise manner. While some studies found a less favorable view of telehealth among older patients, this survey demonstrated a high level of satisfaction across all age groups. This is consistent with more recent literature, suggesting that older patients are becoming more accepting of telehealth as a care delivery model. 11 This trend is likely due to more frequent use of real-time video communication technologies in everyday life, less cumbersome technology, and improved audio-video quality. The ability to utilize common platforms, such as FaceTime ® and Zoom ® , also likely made the prospect of a telehealth interaction with a provider less intimidating for patients.

Patients seen for a diverse array of reasons all exhibited high satisfaction with their care and were accepting of telehealth. Of those seen for hepatic, biliary, and pancreatic disorders, 77.3% expressed willingness to utilize telehealth in the future, which did not meet the high satisfaction threshold of 80%.

However, 86.4% of these patients indicated that their concerns were addressed by the provider, and this is consistent with the findings of a recent study by Serper, et al. 21 Patients seen for follow-up care, medication-related issues, and pre-procedural appointments were particularly satisfied with their virtual visits. In these groups, telehealth is particularly effective because it is much more convenient for the patient and thus improves the overall care experience. Among both patients and providers, the inability to perform a physical exam has been noted to be a potential barrier to telehealth. 6 However, the vast majority of provider respondents felt as if they were able to formulate an acceptable care plan despite this limitation and were very willing to utilize telehealth in the future. The use of telehealth in GI care fulfills the first aim of healthcare improvement by enhancing the care experience for both patients and providers.

The second identified aim involves reducing healthcare costs through improved efficiency.

Telehealth reduces the time and cost associated with a traditional office visit, including travel, missed work obligations, and childcare arrangements. 11 From the patient perspective, convenience and decreased cost are often cited as major reasons for their satisfaction with telehealth. This is of particular importance to those with limited mobility, non-traditional work hours, and lower socioeconomic status. For patients that utilize public transportation or caregivers to travel to appointments, a short appointment may require hours of logistical planning and come at significant financial cost. Enabling these patients to interact with their providers from home would make accessing the healthcare system both less expensive and logistically less challenging. 11 From the practice perspective, telehealth has the potential to be a costeffective care delivery model by reducing personnel requirements and other expenditures. 22, 23 Continuing to permit the use of more accessible technologic platforms for telehealth will lead to further cost-savings.

Telehealth also improves efficiency during times of disruptions to the healthcare system, such as the COVID-19 pandemic, when the resultant cost savings mean that resources can be invested in other critical needs. As such, telehealth serves as an innovative addition to the healthcare system's response to natural disasters. 15 The rapid implementation and utilization of telehealth during the COVID-19 pandemic represents the first large-scale use of this care delivery model in this setting. The transition to telehealth in place of most in-person encounters allowed patients to continue to receive care while reducing the risk of infection and maintaining high patient and provider satisfaction. This is of particular importance for elderly and immunocompromised patients and those with chronic health conditions, for whom an infection would significantly adversely affect their health and be more costly to the system as a whole. In addition, telehealth enabled practices to avoid the costly and complex task of contact tracing if a patient or employee were to be diagnosed with COVID-19. Given the current uncertainty regarding the possibility of re-infection and concerns of subsequent outbreaks, the continued use of telehealth services is critical for individual patient wellbeing and the greater public health. Thus, telehealth improves efficiency and reduces cost for both patients and practice groups, during times of routine care and, importantly, when the healthcare system is disrupted. The final aim, improved patient outcomes, is an area that requires additional study in GI patients, though better outcomes have been shown in other settings. 11

The COVID-19 pandemic required an unexpected, immediate expansion of telehealth usage. To facilitate this, regulatory changes that addressed several well-documented barriers were instituted. These included increasing payments for telehealth encounters, permitting audio-only communications, and allowing for the use of "everyday communication technology" that is not specifically HIPAA-compliant. 5 These changes allowed at least 37 community-based GI practices across the nation to conduct 51,187 telehealth encounters in March 2020 and 90,084 in April, an increase of 76.0%. This number likely represents only a very small percentage of the total telehealth visits conducted in the United States over the past several months. Preserving these regulatory flexibilities is critical to the expansion of telehealth and will thus contribute to overall healthcare system improvement.

During the COVID-19 pandemic, telehealth usage increased dramatically in order to reduce disease transmission while ensuring continuity of care. This is the first survey of community-based GI patients and providers to demonstrate high satisfaction and acceptance with virtual encounters. The results of our surveys are noteworthy for several reasons. While previous studies have investigated provider and patient satisfaction in the provision of urology, dermatology, and urgent care, this is the first to evaluate provider and patient satisfaction it in the setting of community-based general GI practices. 7, 10 Additionally, it is the first to demonstrate that stakeholders experience high satisfaction with and acceptance of telehealth when it is implemented in response to a disruption of the healthcare system. Regulatory changes enacted by CMS and private payers in March 2020 enabled telehealth to fulfill two of the three aims of healthcare improvement by enhancing the care experience and improving costeffectiveness. Further research is needed to determine the effect of telehealth on patient outcomes. Figures  Figure 1: 1a , Patients' approval rates to telehealth stratified by age groups. 1b, Providers' approval rates to telehealth. GI, gastrointestinal. 

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