Patients’ experience of telehealth clinics during the COVID-19 pandemic: Cross-sectional study
Department of Family and Community Medicine, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
Research & Academic Accreditation Office, King Abdullah bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
Patients’ Experience Office, King Abdullah bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
Global Center for Mass Gatherings Medicine, Public Health Agency, Ministry of Health, Kingdom of Saudi Arabia
Department of Public Health and Community Medicine, Faculty of Medicine, Zagazig University, 11459 Zagazig, Egypt
Department of General Practitioners, Royal College of General Practioners, London, United Kingdom.
*Correspondence: Samar Ahmed Amer, Department of Public Health and Community Medicine, Faculty of Medicine, Zagazig University, 11459 Zagazig, Egypt (e-mail: dr_samar11@yahoo.com).Abstract
Globally, the Coronavirus disease (COVID-19) pandemic in 2019 has accelerated the adoption of telehealth technologies. The implementation of the Saudi Telemedicine Network (STN) and other digital health initiatives, such as the telehealth clinic (THC) at King Abdullah bin Abdulaziz University Hospital (KAAUH), exemplifies this trend in Saudi Arabia. The aim of this study was to explore the patients’ experience of THC in KAAUH during the COVID-19 pandemic and their’ beliefs about their readiness to replace the traditional onsite clinical visits with THC from March to September 2020. A cross-sectional study targeted all 1398 patients who utilized THC at KAAUH. A self-administrated, validated survey collected the data. The survey used a Likert scale and included questions on satisfaction with THC services and the perceived effectiveness of telehealth as a substitute for in-person visits. The collected data was analyzed using frequency and percentage. A total of 252 patients responded to the THC postvisit survey. Overall, 217 patients (86%) were satisfied, 32 patients (13%) were dissatisfied, and only 3 patients (1%) were neutral about THC. Most patients (65.5%) agree that THC provided enough information about their health conditions, which can substitute for clinical visits. About 18.3% of patients were neutral, while 16.3% disagreed with the effectiveness of THC services and believed that they could not replace onsite visits. During the COVID-19 pandemic, most patients were satisfied at KAAUH-THC in Saudi Arabia and believed that it could replace the onsite visit to a physician’s clinic. The 2 main causes of the patient’s belief that THC could not replace an onsite clinical visit were: First, nonadherence to appointments led to missed calls and a complete medical service. Second, the patient’s perception is that a physical examination and lab investigation cannot be completed through THC.
1. Introduction
Over the past 10 years, the dynamic advancement of medical technology and the internet has transformed global digital delivery and management of healthcare services.[1] Telehealth and telemedicine have become widespread to bridge the challenges of time, distance, and convenience in the delivery of care by ensuring that health care is provided remotely.[2]
The term telehealth, first used in the 1970s, was defined by Bashir and Bastola as “the integrated use of electronic information and telecommunications technology to support all aspects of remote clinical health care, patient and professional health-related education, public health, and health administration through computer-based technologies.”[3,4] The term telemedicine refers to the practice of providing healthcare services remotely by utilizing available technologies. Betancourt et al (2020) argue that both terms are collectively similar.[5]
The variety of definitions of telehealth is constantly expanding because of its capacity to respond to altering technological breakthroughs and adapt to altering requirements and settings.[6] Despite the interchangeability and synonymy of both terms, telehealth boasts a wider scope and more frequent usage.[7]
Healthcare services underwent fundamental changes during the Coronavirus disease (COVID-19) pandemic in 2019. At the beginning of the crisis, the focus was mostly on containing the infection’s spread and managing COVID-19 cases. As the pandemic endured and patients’ needs for healthcare increased, concerns have arisen about the indirect effects of the pandemic on patients with chronic medical conditions, particularly those who require close follow-up and medication refill services.[8] Telemedicine had more positive effects on patients’ satisfaction than traditional physical visits did. Because telemedicine makes it easier for people to get healthcare at home. It also lowered costs, made the service more flexible, and reduced risks.
Patients who experienced telehealth (video or virtual visits with their healthcare providers, which is an experience that many had not encountered in the past) showed increased satisfaction in the US, making these virtual technologies viable alternatives to in-person visits. The removal of privacy and financial disincentive barriers allowed more patients to experience telehealth provision, whereas in Australia, individuals had a worthwhile experience with telehealth and hoped to continue experiencing it even after the pandemic.[7] Despite this fact, people’s experiences with telehealth during the pandemic have proved that it is a valuable model of care for current as well as future practices, but it has faced various challenges that have limited its adoption. For instance, 75% of telemedicine projects have failed in the country, and this percentage has risen to 90% in emerging nations.[2]
In 2011, the Ministry of Health (MOH) in Saudi Arabia (SA) introduced the first telemedicine network and implemented various forms of eHealth to replace face-to-face consultations in clinical settings, including the Saudi Telemedicine Network (STN). To achieve the third objective of the 15-objective Saudi National Transformation Programme (NTP) 2030, the MOH has launched over 19 mobile apps and a group of projects, including the “Mawid” application[9] and the telehealth clinic (THC). The MOH plan aims to enhance the effectiveness and efficiency of the healthcare sector through information technology and digital transformation, while also promoting the use of telemedicine in SA.[10]
The Family Medicine Department at King Abdullah bin Abdulaziz University Hospital (KAAUH) launched the THC early in 2020 to handle all medical cases, except for emergency management. In March 2020, KAAUH instructed the patients to minimize Outpatient Department (OPD) visits and announced a hotline for medication refills with possible home delivery if requested. In July 2020, all medical OPD clinics were converted to THC with in-person bookings for flu and employee health clinics.[11] Patient experience at KAAUH is an indicator of our commitment to ensuring convenient accessibility to our services for our esteemed patients. We conducted this study to explore the patients’ experience in terms of satisfaction with THC services and the perceived effectiveness of THC as a substitute for in-person visits at KAAUH during the COVID-19 pandemic from March to September 2020.
2. Methodology
2.1. Study design and setting
A cross-sectional study was conducted at KAAUH-THC during the COVID-19 pandemic from March to September 2020. KAAUH is situated in the southern part of the city, on the Princess Nourah bint Abdulrahman University (PNU) campus. It has 59 outpatient clinics and a 406-bed teaching hospital. The hospital, officially inaugurated on March 28, 2017, received accreditation from JCIA, CBHAI, and the Ministry of Education. In its entirety, the study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist.[12]
2.2. The target population
This study targeted all 1398 patients (PNU faculty, students, and the community) who utilized at KAAUH-THC during the COVID-19 pandemic from March to September 2020 in order to obtain the required medical services, except for emergency management, including the cold cases referred by family physicians, check laboratory or diagnostic workups, manage the patient, improve remote healthcare delivery, and rebook in-person visits in the OPD if required.
2.3. Data collection tool
The survey consists of 2 main questions: The first question inquired about the patients’ satisfaction with the services provided during the THC, specifically the medical services and the provided information. The second question examined the patients’ perspectives on whether THC can replace onsite visits to the clinic.
Both survey questions included scaled responses. We chose the 3-point scale from 1 to 3 (1 = dissatisfied, 2 = neutral, and 3 = satisfied) due to its simplicity (rapid, straightforward to apply on all calls, acceptable, and saving cost), although it may limit the granularity of responses.
2.4. The data collection method
The data were collected through pretested, validated online, and self-administrated questionnaires. The Arabic and/or English survey link was sent to the patients 1 week after receiving the THC care via SMS or through the KAAUH Patient Application, which is available for free installation.
2.5. Statistical analysis
The collected data was coded and analyzed using SPSS version 21 as descriptive statistics. The results were represented using frequency (F) and percentage (%).
2.6. Ethical approval
The Princess Nourah bint Abdulrahman University ethical committee, registered under the number 21-0191, received institutional review board (IRB) approval on March 29, 2021, to conduct this work. Before participating in the telehealth survey, we asked all participants to complete and check an informed consent box. Participation in the survey was voluntary and related to the patient’s healthcare appointment. Checking the consent box and completing the voluntary survey were considered evidence of providing valid, informed consent. The IRB application for this study, which received approval, described this consent process.
3. Results
3.1. The response rate to the evaluation text messages
Out of the 1398 patients who utilized the KAAUH-THC, only 252 (18.0%) patients responded to the THC postvisit survey.
3.2. The level of satisfaction with the THC service
Figure 1 shows the satisfaction rate among KAAUH patients using THC services. It clearly shows that most patients were satisfied with the service provided by THC.
About 217 (86%) patients were satisfied with the KAAUH-THC services. On the other hand, 33 patients (13%) were dissatisfied with THC services, and only 3 patients (1%) chose to be neutral about THC.
3.3. The patients’ readiness to replace physician onsite visits by THC service
Figure 2 shows that most of the patients (65.5%) agreed that the effectiveness of the THC service was that they had enough information about their health conditions via THC, which can substitute for an onsite visit to the clinic. In contrast, 18.3% of the patients are neutral about THC, and 16.3% disagree with the effectiveness of the THC service and believe that THC cannot replace an onsite physician visit in the clinic.
3.4. The main causes that patients believed that the THC couldn’t replace the onsite visit to a physician clinic
Figure 3 shows that among those 16.3% (n = 41) patients who did not believe in the effectiveness of THC replacement of an onsite visit to a physician clinic, 33.9% (n = 18) revealed that the reason was due to not receiving the physician call on the scheduled time, which caused the patients to miss the entire medical service. In addition, 34.2% (n = 14) of the participants revealed that they needed physical examinations and laboratory investigations, which were not achieved via THC, while the remaining 9 (21.9%) reported due to other causes.
4. Discussion
Globally, the COVID-19 pandemic has accelerated the adoption of telehealth technologies. The implementation of the STN and other digital health initiatives, such as the THC in KAAUH, exemplify this trend in SA and put telehealth under pressure.[6] Most patients in this study reported satisfaction, effectiveness, and readiness to replace onsite clinical visits with THC during the COVID-19 pandemic.
4.1. The response rate to the evaluation text messages
Out of the 1398 patients who utilized the THC at KAAUH, only 252 (18.0%) patients responded to the THC postvisit survey. This is A suboptimal participation rate is a common weakness of patient satisfaction surveys. This may be attributed to the fact that some patients may be unable to participate because of difficulties in communicating with the link or SMS, cognitive limitations, drug or alcohol dependence, psychiatric diagnosis, sight problems, language barriers, physical limitations, or mental problems.[13–18]
4.2. The level of satisfaction with the THC service
The high satisfaction rate of 217 (86%) aligns with similar studies in telehealth, suggesting that convenience and reduced risk of infection are significant factors in patient satisfaction.[5,19,20] The THC provided convenient and effective healthcare services during the pandemic, leading to high patient satisfaction. The role of THC in providing a wide range of healthcare consultations in a variety of sectors including increasing the number of patients who access health services at a low cost, reducing the time needed, reducing appointment delays, travel time for referrals, transportation costs, and money expenditures, diminishing the risk of exposure to infectious diseases during the pandemic and time off work, minimizing human error, reducing burnout associated with staff shortages, fostering risk mitigation, improving communication between patients and specialists, making patient data more accessible and convenient, doctors can share a variety of persistent patient data that can be utilized to monitor, assess, and evaluate the patients’ health in far-flung locations and in medical emergencies. It is proven to be safe, effective, patient-centered, fast, efficient, and egalitarian.[5,19,20]
Only 3 patients (1%) chose to be neutral about THC, whereas 33 people (13%) expressed dissatisfaction with THC services. THC represents a relatively new and potentially groundbreaking technological innovation. The technology required for virtual visits may be challenging for patients and clinicians to set up, wasting time and resources. The findings of[21]could potentially shed light on this issue.[20] Ahmed et al's[22] and Alkamel et al's[23] research showed that a few HCWs do not understand telehealth, even though more than 80% of the professionals in the study had some comprehension of the technology. In addition, during virtual visits, some patients could find it challenging to access specific locations for speaking privately with clinicians.[24]
4.3. The patients’ readiness to replace physician onsite visits with THC service
Traditional face-to-face meetings between a clinician and a patient took place in a physical location. A new field of medicine where doctors primarily deliver care online was given the name “medical virtualist” 3 years ago.[20] THC was legalized in SA as a medical virtualist.
In this study, the majority of the patients (65.5%) had enough information via THC to substitute for an onsite physician visit in the clinic. This may be explained by what Bashir and Bastola reported,[4] based on which technology is an important part of training for both research and clinical practice. Patient adaptation to THC varies across different times, practices, and locations; for instance, Alharbi et al (2021), Nanda and Sharma (2021), and Gustke et al (2000) reported results that were nearly identical.[24–26] In Jeddah in 2021, more than 90% of nursing students used Internet-based technologies for health education.[27]
In spite of the benefits, we reported that 18.3% of the patients are neutral about THC, and 16.3% disagree with the effectiveness of the THC service and believe that THC cannot replace an onsite physician visit in the clinic. Higher percentage reported by Nasser et al (2021): Up to more than half of the patients stated that they would prefer to have a physical setting consultation in the future rather than a telehealth consultation.[28]
The results of this study showed that cultural and religious issues are important in the context of remote dermatology. Of the 166 patients studied, 23 (14%) refused to take photographs; most of them cited religious reasons.[29] Considering those studies, future research is recommended to implement video calls in KAAUH THCs and explore the patient experience of patients who required a face-to-face visit to a physician in the clinic, considering the importance of cultural and religious principles in the country.
4.4. The main causes of negative perceptions about THC among patients
In this study, 16% of patients who believed that THC could not replace an onsite physician visit justified their negative perceptions.
Despite the advantages of THCs, there are 2 main drawbacks to THC at KAAUH. The findings revealed that the majority of our patients (44%) who had negative perceptions about THC were due to their nonadherence to the appointment of the calls, which led to their failure to receive the THC call at the scheduled time, which caused the patients to miss the entire medical service and affected their experience with THC.
Virtual visits are not always an effective strategy to cope with no-shows. During virtual visits, some patients could find it challenging to access distinct areas for speaking privately with clinicians. Thus, there is a need for better administrative coordination of THC at KAAUH to support physician calls to patients.[30,31]
The majority of patients who participated in interviews believed that their local cultural background was to blame for this nonadherence, which is a critical factor in the implementation of telehealth. Patients, especially women, may be uncomfortable with video consultations or sharing images for remote consultations. An earlier study explored the cultural issues of mobile tele-dermatology.[18] Moreover, patients may not be able to use the digital tools required for virtual visits if they have insufficient socioeconomic means, little access to the Internet, a cognitive disability, or other physical limitations.[22]
Second, the patient’s perception is that THC causes an inability to conduct a physical examination and laboratory investigation. The inability to interact with a healthcare provider face-to-face is the most frequently mentioned downside of THC. These findings agree with those of Alharbi et al (2021) that have been conducted in SA.[22] On the other hand, this contrasts with the findings of Sykes’ (2020) study conducted in the United States, which revealed that respondents’ greatest concern about the quality of telehealth was the most important disadvantage of THC.[32]
4.5. Limitations
This suboptimal response rate of less than 20% may increase the risk of selection bias and introduce nonresponse bias, potentially skewing the results towards those with stronger opinions about their telehealth experience, which may affect the validity of the results. Despite most patients expressing satisfaction, the suboptimal response rate, lack of demographic data, and confinement to a single secondary care setting in SA may limit the generalizability of the results.
5. Conclusion
During the COVID-19 pandemic, our findings showed that most patients receiving THC at KAAUH had a high level of satisfaction with SA telehealth services and believed that THC could replace an onsite visit to a physician’s clinic. The patient’s belief that THC couldn’t replace an onsite clinical visit stemmed from 2 main reasons: First, nonadherence to appointments led to missed calls and a complete medical service. Secondly, the patient believes that THC cannot conduct a physical examination or lab investigation.
This study demonstrates the high potential and patient acceptance of telehealth services during the COVID-19 pandemic in SA. To maximize the benefits of telehealth, ongoing efforts should focus on improving technological infrastructure and addressing specific cultural and logistical challenges.
6. Recommendation
Our findings indicate that KAAUH needs a comprehensive THC system that includes administrative coordination to support physician calls to patients enhance patient experiences, and maximize benefits.
- Educating and training healthcare professionals. To improve proficiency in telehealth, the nursing education curriculum should incorporate telehealth or telemedicine studies, thereby enhancing future patient experiences and outcomes. This will ensure that all healthcare professionals have the necessary knowledge of the technology.
- Investing in telehealth could help reduce the effects of the medical staff shortage by allowing the medical staff to easily access patient information, provide patient education, and promote patient autonomy for many patients.
- The availability of video calls with essential ethical considerations, the scheduling of allied health services, and, if necessary, the referral to an onsite visit are all important factors to consider. Therefore, this is where research should focus to provide more detailed evidence of how telehealth impacts medical practice.
- To provide more precise evidence of how telehealth influences medical practice, the main telehealth research should focus on this topic.
- A more thorough patient interview can yield important data for THC development. Healthcare trends and patient requirements will change over the next few years. Therefore, it is necessary to be ready to accept telemedicine to improve quality-of-care outcomes.
- Doctors treating patients who miss appointments may use no-show policies. These policies can include polite reminders, no-show fees, and special exclusions.
- A future comprehensive system for THC is required at KAAUH and should include administrative coordination, availability of video calls if required, with necessary ethical considerations, booking of allied health services, and referral to clinics if required. Furthermore, more in-depth research and patient interviews can provide valuable information for improving THC.
- Future research and practical implementations should focus on longitudinal studies to assess the long-term satisfaction and outcomes of telehealth services. Furthermore, integrating video calls and addressing cultural and religious considerations could improve the effectiveness of telehealth in SA.
Acknowledgments
We would like to express our thanks to Princess Nourah bint Abdulrahman University Researchers Supporting Project Number (PNURSP2024R290), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia. We are grateful to all participants who responded to the survey.