Is virtual clinic the way forward: Patient satisfaction comparing phone clinic vs. conventional clinic
Author: Benjamin Wall*
Date: 10-12-2020
Introduction:
Outpatient clinics provide a vital role in assessing and treating patients and have traditionally involved face to face consultations with a clinician to diagnose and treat acute and chronic medical and surgical conditions.
Telemedicine, defined as the remote diagnosis and treatment of patients through telecommunications technology, has served as an adjunct to conventional healthcare provision since its earliest published utilisation in the 1970’s.1 However, despite tremendous advances in the accessibility of mobile phones and wireless internet over the last 20 years, the application of this service has not yet been universally adopted, in part due to the perception that is less effective than traditional face to face consultations.2-5
The unanticipated advent of the COVID-19 pandemic on March 11th 2020 precipitated a significant acceleration of this previously sluggish adoption of telemedicine. In an effort to sequester healthcare resources, as well as to limit the exposure of patients and healthcare professionals to the virus, hospital systems worldwide saw the cancellation of elective surgeries and the restriction of hospital visits. Such restrictions have compelled outpatient clinics to implement telemedicine services which are safe and reliable in a time frame of days to weeks. While the rapid adaptation of these systems has certainly proved challenging, we must also consider these adverse circumstances as an opportunity to embrace the technology at our disposal, and in doing so, make significant advances in the quality and efficiency of healthcare services.
The Department of Orthopaedic Surgery at Rockingham General Hospital sees approximately 900 monthly outpatient consultations. 58% of these are fracture clinic patients and 42% are elective patients. Until the emergence of the COVID-19 pandemic, the vast majority of these consultations were face-to-face in nature. From March 23rd 2020, in keeping with the recommendations of the Department of Health of Western Australia, Category 2 and 3 elective surgeries were postponed, and the vast majority of outpatient consultations were carried by telephone.6 All referrals to the fracture clinic were reviewed by a consultant orthopaedic surgeon and triaged as face-to-face (F2F) or telehealth (TH). Elective outpatient clinics were converted into an entirely telemedicine based service, and subsequent face-to-face appointments could be booked only if absolutely clinically indicated. Practitioners were permitted to waitlist patients for elective procedures, but these cases would be flagged as requiring pre-operative clinical examination prior to surgery when permitted by government restrictions.
Telemedicine poses many opportunities in the improvement of patient care, including increased availability of specialised healthcare to underserved geographically remote populations,3,7-10 the streamlining of patient triage,11-15 the decrease of patient expenditures and inconvenience,16-18 and reduced nosocomial disease exposure to vulnerable patients. Furthermore, in a climate where clinical demands so often outweigh available resources, telemedicine has been shown to be cost-effective,19-22 while also increasing the overall efficiency of healthcare systems.23 Although studies have revealed telemedicine to be a safe and robust pathway in the management of specific orthopaedic presentations,7,8,11,24-26 it is important to maintain patient satisfaction as a key indicator of healthcare quality, regardless of its delivery modality. If patients are not happy with the service, it will inevitably become redundant.
The primary aim of this pilot study was to assess patient satisfaction outcomes with the provision of a predominantly telemedicine-based orthopaedic service. Such outcomes will guide us in the establishment of a patient-centered care pathway that reflects the vast technological advances of recent times.
Method:
Due to the outbreak of COVID-19, and stringent precautions put in place as a result of this, patients were required to attend clinics via the telephone between the dates 30/3/20 and the 30/5/20. These patients were called at their appointment time by a member of the orthopaedic team from resident to consultant grade.
In order to assess patient satisfaction,16 a questionnaire was designed based on previous work as well as through group discussion. It was used to establish a patient’s response to various aspects of the telephone consult. This questionnaire was divided into two parts: part 1 pertained to demographic information for each participating patient, part 2 addressed the response of each patient to the telephone consult.
The questionnaire was used on a retrospective convenience sample of patients who had received a phone consult over the Covid-19 period to determine patients’ preferences of phone consults compared to traditional face to face consultation. As this was a pilot study a sample size calculation was not performed. The target was 100 completed surveys which was felt to be an obtainable number and sufficient to gauge the initial response. The 100 patients were aimed to be taken equally from acute fracture and elective orthopaedic clinics.
Data collection was performed by the orthopaedic department, but these individuals were not were not involved in the original care provided to the patients. To reduce bias the researchers did not identify themselves as members of the orthopaedic department but rather as doctors from the hospital at which this research was taking place.
Patients were contacted by telephone and consented to participate in the research. They had the option of refusing to be questioned and it was explained that this would have no impact on the future care they would receive. The aims and purposes of the study were fully in detail before proceeding with the questionnaire. For those patients below the age of consent the data was retrieved from the next of kin (NOK) who had attended the phone consult on the patient’s behalf.
Demographic information was obtained from the hospital episode statistics (HES) data following discussion and approval from the audit department. Data regarding the patient’s response to the clinic was obtained through use of a Likert scale with responses ranging 1-10 (1 = not at all satisfied, 10 = completely satisfied). Data was collated in a password protected spreadsheet on a trust computer.
Patients were included if they were seen via telehealth within the study period and patients were excluded if they were seen face to face, had a diagnosis of dementia or cognitive impairment, or if they were unable to be contacted.
Results:
In total, 100 patients completed the satisfaction questionnaire - 50 from elective surgery clinics and 50 from fracture clinics. Of the 50 elective surgery consultations, 44 were pre-operative and 6 were post-operative. Elective orthopaedic consultations dealt with a wide range of orthopaedic presentations - 15 shoulder, 14 knee, 9 hip, 2 elbow, 2 foot and ankle and 8 other consultations were included in the survey. Of the fracture clinic consultations, 47 were pre-operative and 3 were post-operative (refer to Table 1). The mean age of study participants was 48.7 years (7 to 85). 41% of participants were male, while 59% were female (refer to Table 2).
Table 2: Participant age summary
|
All patients
(n=100) |
Male
(n=41) |
Female
(n=59) |
<25yrs |
21 |
12 |
9 |
25-49yrs |
24 |
10 |
14 |
50-74yrs |
42 |
16 |
26 |
>75yrs |
13 |
3 |
10 |
The mean time for participants’ one-way commute to the hospital was 21 minutes (2 to 60 minutes) (Refer to Table 3). Only 4% of telehealth consultations resulted in patients being forced to miss work or school. 13% of patients were required to attend the hospital on the day of their consultation for either radiological imaging or for application or removal of casts or splints.
Table 3: Participant one-way commute durations
|
All patients
(n=100) |
Elective
(n=50) |
Fracture
(n=50) |
Mean (mins) |
21 |
18 |
23 |
Std. dev |
13 |
11.7 |
13.9 |
Min (mins) |
2 |
5 |
2 |
Max (mins) |
60 |
60 |
60 |
Table 4 shows mean responses to Questions 1-8 of the questionnaire. Overall satisfaction with the Telemedicine consultations was high with a mean score of 9.00/10 (9.22 in the Elective Clinics, 8.78 in Fracture Clinics). Highest mean satisfaction scores recorded were in relation to the clearness of instruction sent to patients prior to their appointment (9.18/10) and understanding the recommendations of the doctor following their appointment (9.18/10). Lowest mean satisfaction scores were in relation to convenience of the Telemedicine consultation (8.96/10) and waiting time on the day of the appointment (8.96/10).
Table 4: Questionnaire responses
Questions |
Mean |
Std. dev. |
Min |
Max |
The telehealth appointment was convenient |
9.0 |
1.5 |
2 |
10 |
The instructions for appointment were clear |
9.2 |
1.5 |
1 |
10 |
I was satisfied with the wait time on the day of the appointment |
8.8 |
1.7 |
3 |
10 |
The doctor listening to me carefully |
9.1 |
1.3 |
3 |
10 |
The doctor explained things clearly and understandably |
9.0 |
1.7 |
1 |
10 |
I had enough time to communicate with the doctor |
9.1 |
1.5 |
2 |
10 |
After the appointment, I understood the recommendation of the doctor |
9.2 |
1.5 |
1 |
10 |
Overall I was satisfied with the quality of the appointments |
9.2 |
1.7 |
3 |
10 |
In regard to outcomes of the telemedicine appointments, 38% of patients were discharged from the orthopaedic service, 39% required further follow-up appointments, while 23% did not respond to this part of the questionnaire. Prior to their appointment, 51% of patients would have preferred a Face-to face consultation over Telemedicine. Based on their experience of the Telemedicine consultation, 53% of patients expressed a preference for Face-to-face consultations for future appointments, while 47% would prefer a Telemedicine consultation.
Table 5 shows a selection of patient responses to the qualitative component of the questionnaire. Common themes among positive responses included less anxiety related to acquiring a COVID-19 infection, the convenience of not having to drive (particularly in those unable to drive due to injury), feeling less rushed during the consultation and the courteous manner of the doctors. Frequent negative responses included difficulty establishing rapport with the doctor (particularly in first-time consultations), disappointment in a lack of definitive diagnosis without physical examination, and frustration with the Telemedicine appointment not occurring at the exact time assigned - be that too late or too early.
Table 5: selection of patient responses to the qualitative component of the questionnaire
Positive |
“good doctor, well explained, easier with phone consult” |
“Very convenient, less waiting” |
“impressed, no hassle, more informative than expected” |
“Nice not to have to travel” |
“Great service, good communication” |
Negative |
“The doctors expected me to know if something was wrong with my hip replacement” |
“First appointments should be in person” |
“seemed rushed” |
“Frustrating if phone call is not on time” |
“call not at the time stipulated” |
Variable |
All patients
(n=100) |
Elective
(n=50) |
Fracture
(n=50) |
Age |
Min |
7yrs |
18yrs |
7yrs |
Max |
85yrs |
79yrs |
85yrs |
Mean |
48.7yrs |
55.2yrs |
43.9yrs |
Operative status |
Post op |
9 |
6 |
3 |
Pre op |
91 |
44 |
47 |
Orthopaedic issue |
Fracture |
50 (50%) |
0 |
50 (100%) |
Shoulder |
15 (15%) |
15 (30%) |
0 |
Knee |
14 (14%) |
14 (28%) |
0 |
Hip |
9 (9%) |
9 (18%) |
0 |
Elbow |
2 (2%) |
2 (4%) |
0 |
Foot or Ankle |
2 (2%) |
2 (4%) |
0 |
Other |
8 (8%) |
8 (16%) |
0 |
Table 1: Descriptive statistics
Discussion:
The primary goal of this pilot study was to assess patients’ satisfaction in using telecommunication as an alternative means to accessing orthopaedic care, while also reducing their risk of contracting or spreading the COVID-19 virus. Through our questionnaire, we also aimed to analyse various parameters which may be affecting patient satisfaction to allow for the development of departmental telemedicine policies.
From a patient satisfaction point of view, the results of this study indicate a smooth, and well appreciated transition from a predominantly face-to-face orthopaedic service to a telemedicine service. We observed very high satisfaction scores across all parameters, in both elective and fracture clinics, culminating in a mean score of >9.00/10 on the Likert scale. In the qualitative component of the questionnaire, patients frequently acknowledged a high quality of care despite adverse circumstances.
Due to the necessity for a rapid implementation of a service carried out predominantly through telecommunications, and a very limited capacity for face-to-face consultations, it was not possible to perform a randomised control trial between telemedicine and conventional face to face appointments. However, given the central importance of patient satisfaction in the quality of healthcare provision, our department felt it incumbent to record our patients’ experience of such an unprecedented shift in the means of the delivery of orthopaedic care.
A number of studies have recently demonstrated telemedicine satisfaction rates that are comparable to those of conventional orthopaedic in-patient visits.16-18,27-29 They have also shown that patients who experience telemedicine consultations are more likely to opt for this mode of orthopaedic care in the future. In 2019, a Norwegian randomised control trial of 389 orthopaedic patients found 99% of patients rated their consultation satisfactory or very satisfactory, regardless of whether they were assigned to the in-person or videoconference arm of the study.16 In addition, 86% of patients assigned to the videoconference arm expressed a preference for telemedicine for future consultations. Similarly, a non-randomised study in Pennsylvania in 2018 found comparable satisfaction rates between face-to-face and telemedicine visits, while only 8% of telemedicine patients requested in-person care for their next visit.17
Most of these studies took place at tertiary orthopaedic centres, with patients teleconferencing from a regional facility, closer to their homes. An economic evaluation performed on the Norwegian randomised control trial found patients were required to travel a mean one-way distance of 248km, with a mean one-way travel time of 4 hours and 37 minutes, in order to attend face-to-face consultations.21 In contrast, Rockingham General Hospital is a regional orthopaedic centre, with patients in this study having a mean one-way travel time of only 21 minutes. In addition, 13% of patients were required to attend the hospital on the day of their telemedicine appointment for imaging or cast application. Cost-effectiveness for both healthcare providers and patients, including reduced travel costs, is frequently described in the literature as a major benefit of telemedicine.19-21,30-32 Due to the reduced distances compared with other studies this may explain why only 47% of patients in our study expressed a preference for telemedicine for future visits despite achieving very high satisfaction rates.
Lack of technology literacy and access,33,34 as well as high implementation and maintenance costs35,36 are often cited as challenges to the adoption of telemedicine. Consultation delays due to technical difficulties can also significantly reduce the efficiency and patient satisfaction associated with the modality. Due to the need for a rapid implementation of remote consultations in our study, as well as a lack of internet and video-conferencing facilities at the hospital, all telemedicine visits were carried out over phone in this study. However, our results show that patients found this modality to be extremely convenient and accessible. Patients were not required to attend a remote site for video-conferencing facilities, were not faced with the frustration of technical delays and experienced minimal disruption of their daily activities. We recommend further cost-benefit analyses be carried out into video-conferencing versus standard phone consultations.
In the qualitative component of the study, constructive feedback was encouraged so as to highlight aspects of the telemedicine service which warranted modification. Because telemedicine consultations were often more efficient, we were often running ahead of time and therefore calling patients earlier than their allotted time schedule. This was reflected by the fact that some patients expressed dissatisfaction due to not receiving the phone call at the exact time allotted to them in their appointment. In future we would recommend assigning patients with a broader time range during which they would be called, as opposed to a specific appointment time. In other cases, patients disclosed frustration with an inability of the physician to arrive at a definite diagnosis due to a lack of physical examination during the consultation. Although this is certainly a major drawback to telemedicine as a healthcare modality, the phone consultation often acted as a valuable tool in initiating a diagnostic and therapeutic care plan, whilst also minimising patients’ risk of acquiring COVID-19 infection.
While patient satisfaction was the primary focus of our study, a review of the pertinent literature reveals a number of additional benefits of telemedicine in the provision of orthopaedic care. Telemedicine poses a significant economic benefit with numerous financial analyses indicating the cost-effectiveness of the modality when compared with conventional visits.19-21,30-32 Virtual clinics are not only cost-efficient, but also time-efficient for both patients and physicians. Travel and consultation times are decreased, while the utilisation of telemedicine as a triage tool reduces the number of emergency department referrals requiring a face-to-face consult.15 Access to specialist care is also consistently cited as a significant benefit of telemedicine, removing many of the geographical and logistical barriers that would otherwise prevent many patients from availing of such services.3,7-10 In addition to the well-documented health benefits of decreased exposure to the hospital environment, telemedicine also poses the theoretical benefit of reduced mobilisation on the often-compromised musculoskeletal system in orthopaedic patients. With virtual orthopaedic care in its relative infancy, it is difficult to conclude emphatically on the long-term accuracy of this style of care. However, early research reveals efficacy and accuracy levels comparable to those of face-to-face consults.
With such a lengthy list of benefits, one might question why telemedicine utilisation rates ranged between only 2.4% and 10% prior to the advent of COVID-19. The following challenges may explain such poor uptake figures. Physical examination remains a key component of the orthopaedic consultation.22 Throughout our study, both patients and physicians revealed their frustrations at the inability to arrive at a conclusive diagnosis due to the lack of examination. The current pandemic has certainly prompted the development of various virtual assessment tools,37 however the efficacy of the tools has not yet been thoroughly investigated. The lack of physical examination during this study also underlined the fact that virtual clinic visits may only be suitable for certain clinical presentations. While many simple fracture presentations were easily managed through radiological observation and phone consults, many of the more subtle orthopaedic presentations such as ligamentous laxity were not so amenable to remote care. Additional challenges to the widespread uptake of telemedicine by both physicians and patients include lack of awareness of the modality,33 poor levels of technological literacy and access,22 lack of perceived benefit38 and potential medicolegal exposure.39,40
While the results are promising, it is important to interpret them in light of this pilot study’s limitations. Through this questionnaire, we have sought not to demonstrate statistical significance, nor drastically revolutionise the means in which orthopaedic care is delivered. Rather, this study offers a valuable snapshot of the patient’s perspective of a rapid implementation of telemedicine services amid a global pandemic and provides useful information for the ongoing use of telehealth in appropriate patients. During this period, healthcare providers have been reminded of the importance of minimising the exposure of patients to the risks of a hospital setting, particularly for those who are most vulnerable in our society. As such, the present study highlights the exciting potential of telemedicine in the future of orthopaedics, while simultaneously emphasising the unending value which patients place in the human touch.
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