Telehealth User Experiences During COVID-19: A Case Study of Outpatient Cardiovascular Clinics Affiliated With a Large Academic Practice

ABSTRACT

Objectives: The COVID-19 pandemic led to a rapid and universal uptake of telehealth, but little is known about satisfaction with telehealth in a cardiovascular medicine setting. We examined providers’ and patients’ perceptions about barriers to successful telehealth use and the quality of visits after the first peak of the COVID-19 pandemic.

Study Design: Cross-sectional observational study between May and September 2020.

Methods: At a large academic cardiology practice, an anonymous online survey was sent to providers. Patients attending these clinics completed an anonymous survey regarding their last cardiology telehealth visit, which was through either MyChart video calls (Epic) or audio calls by phone.

Results: The top barriers reported by the 43 providers who completed the survey were lack of vitals/electrocardiogram (80%), internet quality (64%), and patients experiencing technological challenges (61%). More than two-thirds transitioned their practice to greater than 75% telehealth during the pandemic, and 58% expected to offer up to 25% of their care through telehealth after COVID-19. Of the 64 patients, top barriers to telehealth use included poor audio (18%) and video (12%) quality and familiarity with technology (18%). Although 49% rated the telehealth visit better than or just as good as an in-person visit, 31% rated it worse. The majority (66%) would definitely or probably use telehealth again.

Conclusions: In a cardiovascular setting with older patients, top barriers to successful telehealth use were related to technology. For practitioners, reported barriers included obtaining diagnostic information and technology-related challenges for patients. Although they were ambivalent about quality, most patients planned to use telehealth again.

Am J Accountable Care. 2021;9(4):21-26. https://doi.org/10.37765/ajac.2021.88803

Telehealth rapidly emerged as an essential method for care during the COVID-19 pandemic.¹ Prior to the pandemic, telehealth in the cardiovascular medicine setting was predominantly used for the management of heart failure² and remote cardiac monitoring,³ with little use in other outpatient cardiovascular settings. In addition to traditional barriers to telehealth use, including reimbursement and cost,⁴ the field of cardiology faced the challenges of integrating remote monitoring devices and attaining comparable clinical outcomes compared with traditional in-person visits.⁵

Recent publications have focused on guidelines for telehealth use in cardiovascular clinics since COVID-19 began, detailing patient selection and how to conduct visits,⁶ yet there is limited research showing patient or provider satisfaction with outpatient cardiovascular telehealth visits during COVID-19. Studying a large academic cardiovascular medicine practice, we examined, from both the provider and patient perspectives, (1) common barriers to the delivery of telehealth care as a substitute for in-person outpatient care and (2) satisfaction levels with and likelihood of future use of telehealth care.

METHODS

In this prospective observational study, we surveyed providers’ and patients’ perspectives on telehealth at a single academic medical center. Telehealth visits consisted of video calls that were performed through MyChart (the patient portal of the Epic electronic health record [EHR] system) and audio calls done by telephone. Patients who screened negative for COVID-19 symptoms before their visit chose whether to participate in in-person or telehealth visits. If patients did not already have or chose not to sign up for a MyChart account, telephone calls were conducted. Otherwise, decisions to use phone or video call were based on patient preference when scheduling visits. Patients and providers who participated in telehealth visits received an anonymous survey assessing telehealth use. This study received exempt status under the Yale Institutional Review Board.

Provider Survey

An anonymous online REDCap survey was sent to 206 cardiovascular medicine providers within a single academic center through convenience sampling from May 22 to June 25, 2020 (eAppendix A [eAppendices available at ajmc.com]). Cardiovascular fellows, attendings, or nurse practitioners who provided cardiovascular care across the health system who had at least 1 telehealth visit since the COVID-19 era were eligible. No exclusion criteria were defined.

Information about clinician characteristics, as well as visit characteristics and barriers regarding telehealth visits over the last week, was collected. Satisfaction with telehealth and likelihood of future telehealth use were rated on a 5-point Likert scale, which we broke down into satisfied (rated as “very satisfied” or “satisfied”), neither (rated as “neither”), or unsatisfied (rated as “very dissatisfied” or “dissatisfied”).⁷

Patient Survey

The patient survey was collected from July 31 to September 20, 2020 (eAppendix B). Adult patients who visited the 3 primary vascular medicine clinics affiliated with the health system who recently had a telehealth visit for cardiovascular medicine care services within the same academic center where providers were surveyed were eligible. Surveys were printed out and completed by English- or Spanish-speaking patients at an in-person cardiovascular visit regarding their last cardiovascular telehealth visit.

Information about patient characteristics, visit characteristics, barriers, and overall quality rated from 0 to 10 (0 as poorest quality, 10 as best quality) was recorded. Patients were asked whether telehealth was better than an in-person visit and whether they would use telehealth again.

RESULTS

Provider Results

A total of 43 providers completed the survey (response rate, 20.9%); 72% were male and 84% were White. They were mostly attendings (77%); 19% and 5% were fellows and advanced care nurse practitioners, respectively (Table 1).

Age was evenly distributed, and the top specialties were general cardiology (28%), interventional cardiology (23%), and heart failure specialists (16%).

The top 5 barriers to telehealth were lack of vitals/electrocardiogram (ECG) (81%), internet quality (65%), patients experiencing technology challenges (63%), quality of health care delivered (37%), and lacking appropriate devices for telehealth (35%) (Figure [A]).

Overall, 59% of providers indicated that they were satisfied with their telehealth care experience (Table 1). When asked about specific aspects, 84% indicated satisfaction with understanding telehealth, and 70% were satisfied with the audio quality and image quality. About two-thirds of the providers were satisfied with the treatment and education provided, and half were satisfied with the quality of the health care delivered (see Table 1, eAppendix Figure 1, and eAppendix Figure 2 for a complete overview of satisfaction ratings).

Although most providers had no telehealth experience prior to COVID-19 (93%), about two-thirds of providers reported diverting more than 75% of their practice to telehealth during the pandemic (eAppendix Figure 3). After COVID-19, most providers expected having up to 25% of their practice as telehealth.

Patient Results

A total of 64 patients completed the survey (397 surveys were administered, for a response rate of 17.1%); 68% were male and 89% were White (Table 2). The majority (66%) were older than 65 years. Two-thirds of patients were first-time telehealth users, and more than half of visits were audio only.

Fifty-three percent of patients indicated experiencing barriers, with the most common barriers being audio quality (19%), familiarity with technology (19%), video quality (13%), internet quality (9%), access to devices (9%), and having no interest in telehealth (9%) (Figure [B]). Other barriers written in by patients included lack of physical exam (3%), losing video access (3%), and being unable to see facial expressions and body language (1.5%).

The mean quality rating was 8.89 (interquartile range, 8-10). In comparison with in-person visits, 6% rated telehealth better than traditional visits, 43% rated it just as good, and 31% rated it worse (Table 2 and eAppendix Figure 4).

The majority of patients (66%) said they will definitely or probably use telehealth again in the future (Table 2). Of patients 65 years and older, 53% said they would use telehealth again, compared with 91% of those younger than 65 years (eAppendix Figure 5). Seventy-seven percent of patients who had visits that included video said they were likely to use it again, compared with 57% of those who had audio-only visits (eAppendix Figure 5).

DISCUSSION

Our study’s findings suggest that although telehealth has rapidly become a mainstay of health care delivery during COVID-19, there are still significant barriers to implementation. In a cardiovascular setting with older patients using telephone or MyChart video calls (Epic platform), providers felt that top barriers to successful use were obtaining diagnostic information needed to deliver high-quality care and technology-related challenges for patients, but they were generally satisfied with the telehealth experience. Top barriers for patients were related to technology, and most patients expressed an openness to using telehealth in the future.

Our study provides insight into using telehealth as a substitute for routine outpatient care in the cardiovascular setting. In comparison, in a survey of 61 attendings at an academic institution before COVID-19, Donelan et al found that nearly two-thirds of clinicians perceived no difference in quality with virtual video visits, and nearly half reported a higher efficiency in these appointments.⁸ Patients preferred virtual video visits to office visits because of convenience and lack of travel time.⁸ In contrast with our patients, these patients had robust technological support prior to the telehealth visit and were selected by physicians as being appropriate for telehealth. Previous work in our lab also showed that for patients in our health system, 40% saved less than 1 hour and 47% saved 1 to 2 hours with telehealth visits.⁹ Our study is novel in that it captures a comprehensive cohort of patients whose primary option was telehealth, as their preference was heavily biased by the alternative of potential COVID-19 exposure at a medical facility.

Overall, provider acceptance of telehealth was high, but investment in technological upgrades is necessary to continue to enhance the telehealth experience. Lack of diagnostic tools, notably vital signs and ECG, was cited as the top barrier. Some of these limitations can be modifiable with improving technology, such as wearable mobile cardiac monitoring devices.¹⁰ A literature review of remote monitoring interventions for patients with heart failure found that telehealth was generally effective for reducing mortality and rehospitalization.¹¹ Trials with implantable cardiac monitoring devices have had ambivalent results,^12,13 but uptake of these devices in common practice is limited due to technological, personnel, and protocol barriers.⁵ Continued use of telehealth as a viable alternative to traditional visits will require widespread adoption of these monitoring technologies.

Among older patients, the likelihood of using telehealth again was rated lower compared with among those who were younger than 65 years, which may be explained by technological challenges experienced by the aging cardiovascular patient population. Literature suggests that older age may be associated with fewer completed telemedicine visits and less video use.¹⁴ Examples of some ways to overcome age-related barriers include simplifying patient instructions, having patient-support help lines, and encouraging the presence of family members during visits.¹⁵ Although HHS waived penalties for Health Insurance Portability and Accountability Act violations and allowed providers to communicate with patients through everyday technologies (eg, Apple FaceTime, Facebook Messenger),¹⁶ providers in this study still used audio phone calls or MyChart. Clearly, medical telehealth technology must adopt user-friendly principles from other communication applications to foster an easier telehealth experience, especially for the aging US population who is most at risk of contracting COVID-19 and thus the most in need of telehealth services.

Limitations

Limitations to this study included that our sample was obtained by convenience sampling and we had data only from providers who chose to respond to the survey. Further studies should incentivize all providers to respond to the survey to capture a more complete picture of provider experiences. Our patient sampling method may be susceptible to recall bias and may have underrepresented patients who did not have technical difficulties and continued to have telehealth visits. Furthermore, although Epic systems dominate the United States’ EHR landscape, our data are limited in that we looked only at video calls performed through the MyChart patient portal. On the patient side, we were limited by our small sample size and the inability to capture responses from individuals who declined to fill out the survey. We also did not have information on factors that may have affected patients’ experiences, such as socioeconomic status or therapeutic relationship with their provider, and this study is limited to patients in an academic practice and may not represent the larger population. Future studies should also look at the impact of telehealth visits on clinical outcomes and assess whether the lack of a physical exam or inability to perform ECGs will lead to worse outcomes for patients.

CONCLUSIONS

In a cardiovascular setting with older patients, top barriers to successful telehealth use were related to technology. For practitioners, reported barriers to providing telehealth care included obtaining diagnostic information needed to deliver high-quality care and technology-related challenges for patients. Although they were ambivalent about quality, most patients plan to use telehealth in the future. Optimizing technology and integration of telehealth platforms will facilitate successful adoption of telehealth care after COVID-19.

Author Affiliations: Vascular Medicine Outcomes Lab, Cardiovascular Medicine Section, Department of Internal Medicine, Yale University (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H), New Haven, CT.

Source of Funding: None.

Author Disclosures: Dr Smolderen reports grant support received from Cardiva and a consultancy for Optum Labs LLC. Dr Mena-Hurtado reports consultancies for Abbott, Boston Scientific, COOK and Medtronic, Cardinal Health, and Optum Labs LLC. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); acquisition of data (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); analysis and interpretation of data (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); drafting of the manuscript (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); critical revision of the manuscript for important intellectual content (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); statistical analysis (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); provision of study materials or patients (ML, PL, SL, SN, YC-D, ZA, AB, AA, KGS, CM-H); administrative, technical, or logistic support (KGS, CM-H); and supervision (KGS, CM-H).

Send Correspondence to: Carlos Mena-Hurtado, MD, Cardiovascular Medicine Section, Department of Internal Medicine, Yale University, 789 Howard Ave, New Haven, CT 06520. Email: carlos.mena-hurtado@yale.edu.

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