Telehealth Applications on Continuity of Care, Quality of Care, and Patient Satisfaction in the United States

Meta Analysis / By /

Wendi Wu, MPH1

Author Affiliations
1Western University of Health Sciences College of Osteopathic Medicine of the Pacific Northwest, Lebanon, OR.
PNWMSRJ. Published online Oct 15th, 2020.

Abstract

Background: In healthcare delivery, continuity of care is an important cornerstone in determining the quality of care provided to patients since it affects health outcomes, compliance to medication and recommendations, and provider trust. Telehealth will continue to play a role in the nation’s healthcare landscape as consumers increasingly value convenience of time, location, and the need to meet virtually in the context of a global COVID-19 pandemic. Purpose: This review highlights the effects of telehealth on patient satisfaction and healthcare quality while considering the implications on longitudinal, informational, and interpersonal continuities of care.
Methods: A review was conducted utilizing peer-reviewed journal articles from databases such as PubMed, CINAHL, and Web of Science. Both quantitative and qualitative studies were included in analysis.
Results: Telehealth increased continuity when administered by in-network providers who have a relationship with the patient. While medical guideline adherence and prescribing behaviors varied amongst physicians who used telehealth applications, patient satisfaction remained high if telehealth was administered through their healthcare home. Conclusion: Telehealth can serve populations experiencing barriers to medical care, particularly for regions with physician shortages and in populations with limited access to in-person visits. In order to best serve patients, telehealth must meet criteria for safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Introduction

Telehealth refers to a variety of technologies and methods of delivering health care and education via a virtual interface, including but not limited to video calls, mobile health, remote patient monitoring, etc. Telehealth can be asynchronous (no face-to-face interaction) or synchronous (virtual/remote face-to-face interaction). It can also be offered as an independent application where the patient sees a different healthcare provider each time (no long term relationship) or as a service through their healthcare home where they routinely receive care through an established primary care provider. Telehealth is expected to become a more ubiquitous feature in primary care as the number of virtual doctor visits grew 20% from 1 million in 2015 to 1.2 million in 2016.1 Moreover, around 72% of hospitals and 52% of physician groups offer telehealth options.1 Concerns for telehealth include lack of personal relationships with providers, data insecurity for private health information, and non-coverage from insurance plans. On the other hand, top reasons in favor of telehealth are as follows: convenience, potential cost savings, ease of prescription refills, and more frequent communication with their provider. The specific aim of this review is to analyze the impact of telehealth on continuity of care (CoC), quality of care measures, and patient satisfaction.

Methods and Materials

This review will be inclusive of both qualitative and quantitative peer reviewed studies as pertaining to telehealth. Journal articles will be retrieved from the following databases: PubMed, CINAHL, and Web of Science.

Results

Telehealth has several different modalities, with services available from independent apps or integrated within larger healthcare systems. When Telehealth is used as an independent source of care, it contributes to a fragmented healthcare system and negatively impacts patients’ continuity with their PCPs. However, most research in the current literature looks at telehealth programs integrated within clinics and hospitals and show opposite results. Holyk et al. (2017) conducted a survey on continuity of care (CoC) with 210 patients at Carrier Sekani Family Services (CSFS), a primary care model that combines on-site services with telehealth. Supplementing in-person physician visits with telehealth improved CoC, especially for patients with geographic barriers to accessibility. Participants were surveyed on their perceptions of medical trust, satisfaction, usability, effectiveness, and convenience after using telehealth. Overall, telehealth services (videoconferencing) enriched longitudinal continuity, with 77% of respondents reported being able to see their doctor more regularly and 82% indicating greater ability to attend appointments due to less need for travel. Patients who considered CSFS their healthcare home were more likely to give higher scores for usability, convenience of services, and sustained use.2 In general, telehealth’s aptitude to lower barriers for care improved CoC. Telehealth need not always require advanced technology, systems, or software. Telephone visits have proven to be effective at maintaining CoC as well. Scheduled telephone visits at the Veterans Health Administration (VHA) medical homes allowed nurses to check up on patients continuously. Providers cited higher awareness of patients’ health status and had a higher propensity of involving patients in the medical decision-making process. Because telephone visits enabled scheduling flexibility and did not require transportation, it reduced the likelihood of missed visits; thereby, increasing longitudinal continuity.3

Healthcare institutions may adopt telehealth platforms with the intention of collecting information on patients to inform treatment. Informational continuity is of interest among researchers who seek to understand how telehealth affects care coordination and management for patients with chronic conditions. The Health Buddy Program®, a popular telehealth tool examined by numerous studies on a variety of target populations, has been linked to improved health outcome indicators among the elderly with congestive heart failure and diabetes.4 Vital signs and daily questionnaire answers are collected from patients via the Health Buddy® device and transmitted to case managers who review the data. One advantage is that disabled patients do not have to leave their homes to provide this information. Case managers can then contact those at high risk of deterioration for further medical intervention. Identifying patients’ level of risk at an earlier stage not only improves coordination of care, it helps to maintain significant cost-savings (to be further discussed in a later section).4 Other clinician-supported telehealth tools and kiosks can relay up-to-date patient information, facilitating risk management, timely referrals, and coordinated care.5

There is a fear that telehealth—especially asynchronous modalities that do not require seeing or even listening to a provider—will ultimately lead to tradeoffs with interpersonal continuity, characterized by detached relationships and lack of empathy. However, Holyk (2017) found that medical trust, a fundamental component of interpersonal continuity, was not compromised when using telehealth in lieu of in-person visits at primary care centers, where the difference in mean scores for trust between telehealth and in-person appointments were non-significant at 2 Additionally, focus groups reported that routine telephone calls from Veterans Health Administration medical homes met both patients’ and physicians’ expectations for interpersonal continuity.3 Telehealth fortified patient-provider relationships by easing patients’ accessibility for urgent and routine needs. Although patients were initially wary that phone calls would feel impersonal, they found that frequent contact (longitudinal continuity) actually made them more comfortable with established providers. The convenience of “healthcare at home” has resulted in more positive perceptions of healthcare and even higher praise towards providers from telehealth users. Amongst older patients, the relationship and knowledge of the provider was deemed more essential than immediate access. Telehealth employed for chronic disease management allowed providers to identify and encourage at-risk populations to make lifestyle changes. Diabetic patients who had the opportunity to use telehealth for chronic disease management cited that technology helped them develop closer relationships with providers. Nurses also felt that they were able to build trust and provide patient-centered, culturally appropriate, and linguistically sensitive care through telehealth.6

Consistent consultation and health monitoring via telehealth helps hospitals prevent admission and readmission, contributing to significant financial savings for both individuals and systems. Hospitals suffer economically from high rates of uncompensated care when chronic illness goes untreated or unmanaged. To address this, Mercy Health Center in Texas implemented a Telemedicine Diabetes Disease Management Program featuring Health Hero iCare portals and Health Buddy® devices. Videoconferencing visits, combined with at-home glucose and blood pressure monitoring devices, can be particularly useful for patients with conditions that require constant monitoring. These devices provide an effective and efficient means of delivering care to patients while presenting opportunities for collaboration between physician and patients. Patients in the program had cost-savings of $747 per patient, 32% reduction in inpatient admissions (p<0.07), 34% reduction in emergency room visits (p<0.06), and 49% reduction in outpatient visits (p<0.001). Compared to controls, mortality rates were 2.5 points lower for those in the intervention group beginning the second year of program implementation.4 These results are likely due to enhanced self-management and nurses’ ability to pinpoint high-risk patients for timely intervention.8 Holyk (2017), a study with 210 enrolled participants, showed reduced emergency department visits among 63% of patients and lower transportation out-of-pocket spending for 69% of patients.2

Telehealth can incorporate eReferrals, an electronic referral system amongst clinicians. eReferrals cut wait times for patients while simultaneously improving communication and partnerships among PCPs and specialists.9 Specialized physicians quoted lower rates of inappropriate medical and surgical referrals with electronic methods (2.6% medical and 2.1% surgical) as opposed to paper methods (6.4% medical and 9.8% surgical). Avoidable follow-ups also occurred less when using electronic referrals processes (27.5% medical and 13.5% surgical) over paper-based methods (32.4% medical and 44.7% surgical). These differences were significant at p<0.01.10

Schoenfeld et al. (2015) set out to measure variations in quality measures across eight virtual visit companies among patients who presented one of six common illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent urinary tract infections. Five hundred commercial virtual visits were completed in the study period from May 2013 to July 2014. Completed histories and physical examinations occurred in 69.6% of visits (95% CI: 67.7-71.6%), correct diagnoses in 76.5% (95% CI: 72.9-79.9%), and guideline adherent management decisions in 54.3% (95% CI: 50.2-58.3%). Less than 33% disclosed clinician’s credentials or allowed patients to choose and only 32% discussed side effects of prescribed medications. There were significant differences in diagnosis variations and guideline adherence for the six illnesses of interest, depending on the company. However, mode of communication (i.e. video, telephone, or webchat) did not alter adherence rates.11 Prescribing behaviors also differed. Mehrotra et al. (2013) reported that physicians engaging in eVisits were more likely to prescribe antibiotics for sinusitis and urinary tract infections, using a conservative treatment approach to compensate for the lack of in-person examinations. While eVisits can lower health care spending due to lower reimbursement rates, higher volume of antibiotic prescriptions and misdiagnoses undercut cost-saving advantages.12 While there should be continued research on this topic, quality of care seems to be vastly different between integrated and independent telehealth applications.

Telehealth has been touted as a solution to issues of accessibility due to physician shortages in Midwestern regions of the U.S. Therefore, interventions have been especially of interest among vulnerable populations—such as the elderly, veterans, and rural residents—and show promising results. Jue et al. (2017) set out to examine how technology can broaden access to care for complex cases. The study invited 296 veteran patients in Florida to participate in video chats with surgical oncologists, leading to an 80.7% reduction in travel distance. This translated to savings of $155,627.20 in total Medicare reimbursements during the length of the study. Patients unanimously agreed that they were still able to enjoy the benefits of face-to-face visits, appropriate counseling, and discussion of treatment options’ risks and benefits. While 86% of the patients believed telehealth improved accessibility and gave high patient satisfaction scores (averaging 4.5 on a scale of 5), it was difficult to assess surgical outcomes since the study did not collect necessary data on comorbidities and hospital volume that would invariably complicate the relationship.7

Patient satisfaction either considerably improved or did not change after telehealth usage. In settings that offered telehealth, Gustke et al. (2000) concluded a 98.2% satisfaction rate among 495 participants who received interactive virtual clinical consultations after adjusting for patient age, gender, race, income, education, and insurance. Previous studies on telehealth patient satisfaction averaged around 92.8% (ranging from 77-100%), indicating that results were consistent with previous findings.13 When CVS Health assessed patient satisfaction regarding diagnostic images, usability, provider capacity, quality of care, and convenience for a telehealth pilot program in their Minute Clinics, 34% of 1,734 patients expressed preferences for telehealth and 57% reported telehealth “just as good as a traditional visit”.5 Convenience and absence of wait times were among the main motivators for using telehealth. Individuals with no medical insurance were 21% times more likely to prefer telehealth visits over traditional ones.5 In traditional primary care settings, patients gave significantly higher ratings for satisfaction (p=0.01), effectiveness (p<0.001), convenience (p<0.001), and usability (p=0.01) if they considered the clinic their healthcare home.2 Telehealth strengthens communication, adherence, and patient-provider relationships when integrated with in-person medical offices. Personalizing telehealth services to meet the needs and expectations of patient population enables high satisfaction among users.

Discussion

Telehealth has shown remarkable progress in advancing health outcomes and CoC. Still, there are policy and practice considerations necessary for increasing telehealth uptake. The literature was overwhelmingly in favor of integrating telehealth programs in hospitals and primary care centers. There are factors to consider when doing so. First, telehealth interventions should meet the dimensions of healthcare quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. It must be recognized that telehealth’s return on investments is a long-term matter—reducing waste in equipment, supplies, ideas, and energy. Second, important characteristics of an in-person visit should be adopted and incorporated into telehealth for it be to successful. Crucial information such as medical records, medical images, and medication lists should be available prior to implementation. Rather than relying on physicians to collect this information during consultations, preparation in advance will improve efficiency. Third, telehealth is best operationalized within an organization when implementation decisions are initiated from and supported by frontline workers, such as nurses and physicians. Fourth, organizations should develop user-friendly mechanisms to deliver telehealth that is convenient for both providers and patients. For example, telehealth should be accessible via mobile devices, but extra care is required to ensure that medical information is kept confidential. Patients may feel reluctant to disclose private health information if they do not feel like they are in a safe environment, especially since fundamental elements of the in-person encounter that facilitate data collection are removed. Therefore, telehealth should be respectful and responsive to individuals’ needs so that it is patient-centered. Fifth, it is important to note that not all in-person interaction can or should be replaced with virtual ones; thus, organizations must be strategic about the areas in which they want to offer telehealth. Lastly, telehealth should be equitable and deliver care for those who need it most. When delivered through a physician-led healthcare, telehealth improves communication and coordination between providers for patients with special needs. Telehealth is not a one-size-fits-all solution and must be tailored to fit its intended audience.

Acknowledgements

Thank you to Dr. Renata Schiavo, PhD, MA, CCL at Columbia University School of Public Health for her consultations on this topic and help in proofreading.

References

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Article information:

Published Online: Oct 15th, 2020.

Corresponding Author: Wendi Wu (wendi.wu@westernu.edu)
IRB Approval: No IRB approval was required for research.
Conflict of Interest Declaration: The author(s) have no conflicts of interest to disclose.
Funding Source/Disclosure: No financial support was received.