Introduction

The COVID-19 pandemic called for a change in the way healthcare was delivered to patients in order to comply with social distancing recommendations for public safety and resulted in a dramatic shift from in-person care to a focus on virtual care across the country. The Centers for Medicare and Medicaid Services (CMS) swiftly introduced new reimbursement policy waivers that expanded telehealth coverage, eliminating geographical restrictions, and allowing both the originating and remote sites to be from the home [1]. States passed telehealth parity laws that required commercial payers to cover telehealth services [2]. State licensure requirements were also waived, which allowed licensed providers to provide care across state lines [2]. The aim of this study was to assess patient experiences with telehealth services during the COVID-19 pandemic.

Methods

After obtaining Institutional Review Board (#NCR213713) approval, patients who had at least one virtual visit between April 1, 2020 and March 31, 2021 in an urban university-based outpatient nephrology clinic were surveyed using a web-based survey tool to assess their telehealth experiences (see Supplement for the survey). Patients were identified using the clinic schedule from three faculty physicians who conducted telehealth encounters. Patients who were unable to read or understand English were excluded. Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools [3, 4]. Demographic information collected included name, medical record number, phone number, home address, gender, age, and insurance type. The patient was invited to complete the survey initially on-line by email. For individuals who did not respond to the email invitation or who did not have valid email addresses documented, they completed the survey via phone or mail. Patients rated their overall experience with telehealth encounters during the time period using a Likert scale. The Likert scale had five options: excellent, good, fair, poor, and very poor. Additionally, digital health literacy as well as barriers, such as technical issues, to successfully completing telehealth encounters were assessed. Patient satisfaction was positive if the respondent selected good or excellent. The data was de-identified prior to analysis. Patient demographic information (gender, age, race) were analyzed for number, frequency, mean, standard deviation, median and range as deemed appropriate. Chi square testing was performed to compare frequencies of categorical variables to analyze thematic patterns in survey responses. Similarly, regression analysis was performed to analyze the relationship between the independent variables of interest and patient satisfaction. Statistical significance was defined as p < 0.05.

Results

The demographic results of the survey are shown in Table 1. Out of 791 invitees, 166 patients completed the survey (Fig. 1.). A few patients did not answer all the questions, thus resulting in missing data. Most patients (138/165) reported that their overall experiences with telehealth services were positive while 20/165 reported their experiences to be fair, and seven out of 165 reported that their overall experiences were poor or very poor.

Table 1 Patient characteristics
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Fig. 1
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Inclusion and exclusion criteria of patients. The figure shows the inclusion and exclusion criteria of patients in the final sample

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Most patients (143/166) found that it was easy to make a telehealth appointment. For those who felt that it was not easy to make a telehealth appointment, the majority explained that they had difficulty with appointment scheduling that was not related to the telehealth experience. Many patients (136/163) felt it was easy to log into the virtual visit platform. A majority (107/165) responded that they were willing to use the video feature while 43/165 ranked it neutral and 15/165 did not want to use this feature. The majority of patients (133/166) wanted to have a hybrid model in the future, while 9.6% of patients wanted to have telehealth appointments only, and 8.4% wanted in-person appointments only. The remaining 1.9% of patients did not have a preference.

A large number of patients (132/166) reported no technical issues during their telehealth visits. For those who had technical issues, patients reported that these issues ranged from the call being dropped to audio or video issues. Some patients reported difficulty with logging into the virtual appointments and having limited digital literacy, which led to the video visits being converted to telephone visits instead. The majority of patients (125/162) participated in video visits. Some patients (15/162) did not have camera equipment to have a video visit, while others (20/162) did not know how to use the video feature on the virtual platform. A small percentage of patients (two out of 162) did not want the physician to see them, so they opted for a telephone visit instead.

Most patients (161/166) found their telehealth visits convenient. The number one reason given was not having to worry about arranging transportation. Some other popular reasons included: the doctor was on time to the visit, the visit allowed them the option of not having to take time off from work, and the visit allowed them to have someone else join in the virtual visit. For the few that responded that the telehealth visit was not convenient (five out of 166), they preferred to see the physician in-person. Most patients wanted to continue having telehealth appointments after the pandemic (153/166). Patients explained that telehealth appointments are convenient, especially for reviewing lab results.

A few patients (nine out of 166) reported they were hospitalized between April 1, 2020 and March 31, 2021. Patients (eight out of nine) who were hospitalized during this time period did not think that an in-person visit instead of a virtual one could have prevented the hospitalization, while one person did not respond. Most patients (134/164) were amenable to not having an in-person physical exam. For those who wanted an in-person physical exam, patients felt that it preserved the interpersonal interactions that are important to the physician–patient relationship.

The following variables had no significant impact on overall experience: age, gender, ethnicity, prior telehealth use, wanting only telehealth appointments in the future, insurance type or status (unknown insurance vs. private vs. Medicare/Medicaid), and dropped calls when using telehealth services. Table 2 depicts the positive and negative experiences queried with regards to telehealth.

Table 2 Patient experiences
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Discussion

This study utilizes the unique COVID-19 pandemic situation, where outpatient nephrology care shifted to telehealth-based services, to better understand patient perspectives on this form of service. Our results indicate that the majority of patients had positive experiences overall with telehealth services such that they would prefer to see a “hybrid” model in the future. The majority of patients found virtual visits convenient with few patients reporting technical issues impeding their experiences. Our research revealed benefits and challenges of this new healthcare delivery model as perceived by patients. The challenges reported by some patients included the lack of access to appropriate equipment, which sheds light into health inequities that must be addressed moving forward. These results may help the structure of future telehealth programs beyond the pandemic.

Telenephrology

In nephrology, there is a growing need for telehealth services to increase access to specialty care and reduce health disparities. The 2015 Workforce Report by the American Society of Nephrology found that many nephrology training programs are located in mostly urban settings, far from rural areas where kidney failure rates are high [5]. It has been shown that patients with chronic kidney disease (CKD) in geographically isolated locations are less likely to follow up with nephrologists and receive the effective treatment they need, which ultimately leads to more hospitalizations and even higher mortality when compared to patients who have access to nephrology care [6].

Large healthcare organizations such as the Veterans Affairs (VA) system have turned to telehealth services as a means to provide more cost-effective care and bridge the gap between underserved populations and access to care [7, 8]. The VA leveraged telehealth services as early as 2002 with its Clinical Video Telehealth (CVT) program that aimed to provide patients remote care through videoconferencing in various specialties [7]. One study showed that telenephrology improved patient compliance with appointments and reduced no-show rates as well as cancellations by 50% [7]. Moreover, they hypothesized that this may have been due to decreased travel times to the hospital. Another example of applying telehealth to increase access to specialty care employs electronic consultation (eConsult), which utilizes provider-to-provider electronic asynchronous exchanges of patient health information at a distance to improve the interface between primary care providers and specialists [9,10,11,12].

Nephrologists have had opportunities to conduct telehealth encounters prior to the COVID-19 pandemic [6, 7]. A few patients had prior telehealth experience with one of the nephrologists under a study to improve specialty care access via telemedicine using an urban Federally Qualified Health Center as the originating site [13]. The pandemic has pushed telehealth to the forefront of nephrology care with CMS removing barriers delineated above, licensing requirements, and reimbursement limitations based on visit type [1, 14]. Despite promising results on patient satisfaction and increasing access to care, the future of telenephrology largely depends on future legislation and/or regulations.

Benefits and challenges for patients and practices

Telehealth benefits include convenience, decrease transportation costs and time, increase accessibility to healthcare, and decrease overall opportunity costs (i.e., patients do not need to take time off from work) [15, 16]. There are also many challenges to this virtual healthcare model. Patients require adequate broadband services and access to equipment including a computer, tablet, or a smartphone with video and audio services. Thus, health disparities and social determinants of health pose significant barriers to having a successful telehealth encounter. Equality and social determinants of health need to be addressed.

Having adequate digital health literacy ensures benefiting from telehealth services. Patients with digital illiteracy struggle to join a video visit or set up remote monitoring services, which prevents them from adequately accessing the care they need. Older CKD patients reported that the lack of a physical exam or the difficulty of breaking bad news virtually, especially with connectivity issues, detracted from their experiences and negatively affected the patient-physician relationship and fostered mistrust [17]. Ethnicity and age were shown to negatively impact patient satisfaction, with older individuals and patients of color reporting lower patient satisfaction with using telehealth [17]. These findings are in opposition to results from this study, which showed that ethnicity and age do not play a role in determining patient satisfaction with telehealth services.

For practices, telehealth services increase the number of patients that can be seen, expand specialized care to patients who live far away, and may reduce Emergency Department visits/hospitalizations given more surveillance with remote patient monitoring [16]. Video appointments in particular offer providers a unique opportunity to get a glimpse into the patient’s home to better inform patient care and address social determinants of health. Large practices are able to roll out telehealth programs given that they have robust electronic health record systems, adequate information technology (IT) support for troubleshooting, and adequate funds to purchase Telehealth platform licenses. Additionally, security and privacy concerns remain an issue with telehealth platforms. Purchasing licenses of telehealth platforms ensures Health Insurance Portability and Accountability Act (HIPAA) compliance and mitigates security concerns. For private practices or single provider practices, the economic means to roll out successful telehealth programs may serve as a significant challenge.

Limitations

The small sample size of 21% response rate, despite falling into the average range of response rates of 5 to 30%, may not represent the study population. It is possible that the remaining non-respondents may be older, have poor digital health literacy, or low satisfaction with the tool. Although the majority of patients reported a positive experience, a few patients reported a negative experience because they wanted an in-person encounter or had technical issues with audio and/or video aspects of the visit (Table 2). Furthermore, the nephrology specialty relies heavily on patient symptoms, blood pressure readings and laboratory results and less on physical examination. Therefore, the findings of this study may limit its generalizability to other disciplines and specialty care.

Aspirations and future challenges

Various operational challenges that must be considered for widespread use of telehealth include physician licensing requirements across state lines, telehealth platforms complying with HIPAA and Health Information Technology for Economic and Clinical Health Act requirements, and Business Associates agreement with providers partaking in telehealth services [14, 16]. The fate of licensing requirements will depend on state policies, while the latter can be enforced with the help of an IT officer and the use of HIPAA-compliant telehealth platforms. More studies need to be conducted to determine the cost of care using CMS claims data to determine if this model of healthcare delivery endorses cost-effectiveness. Virtual visits should be used judiciously as these services are not appropriate for all patients but will depend on the physician’s judgment based on in-person visits and triage of virtual visits.

Conclusion

Major findings of this study reveal that patients were not only satisfied with their telehealth experiences overall, but the majority would like to see a hybrid model of care moving forward. The patients praised the convenience of making a telehealth appointment and conducting the virtual visit, with very few patients reporting technical issues. A multitude of factors impact patient satisfaction, with the bulk of these factors directly related to navigation and use of the telehealth platform. In addition, patients enjoyed the decreased transportation costs and time, increased accessibility to healthcare, and decreased overall opportunity costs. Moreover, age, gender, and ethnicity did not impact patient satisfaction ratings as previously reported. Since a limited sample size and only patients receiving care through the nephrology specialty were studied, additional studies will need to be conducted to understand the general patient experience with telehealth.