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A SYSTEMATIC REVIEW OF THE EFFECTIVENESS OF TELEHEALTH/TELEMEDICINE

IN IMPROVING ACCESS TO CARE AND PATIENT SATISFACTION

Student Name

Capstone Project

In partial fulfillment of the degree Master of Public Health

National University

End of Course Date

I accept this capstone project on behalf of the Community Health Department, School of Health and Human Services, National University. Below the faculty who taught the capstone course, and the MPH Program Director will sign.

__________________________________________ ___________

Faculty/Professor of Capstone Date

Brandon Eggleston PhD

__________________________________________ ___________

MPH Program Director Date

Tyler Smith PhD

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Abstract

Objective: This systematic literature review aims to provide a comprehensive synthesis of the impact of Telehealth and Telemedicine in improving access to care and increasing patient satisfaction in various healthcare services before, during, and maybe after the COVID-19 pandemic.

Design: Systematic literature review.

Methods: This systematic review was conducted from January to February 2022 using comprehensive and general searches throughout the National University Smart Search, EBSCO Host, ProQuest, and Google Scholar databases. The publication date range was from 2008 to 2022. After collecting articles from databases, further selection was performed by reading the abstract and results. The chosen articles were further studied by reading the entire text to analyze the research questions.

Results: The articles studied in this systematic review strongly supports that telehealth and telemedicine play an essential role in increasing access to care and improving satisfaction rate. During the COVID-19 pandemic, telehealth and telemedicine were deployed unprecedentedly, providing continuous care for patients of various services.

Conclusion: Telehealth/Telemedicine has a remarkable impact in widening access to care and a high satisfaction rate. It is poised to provide public health, relieve pressure on to healthcare workforce, and help to reduce financial stress to many.

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Keywords: Telehealth, Telemedicine, Barriers, Access to Care, Patient Satisfaction

Acknowledgment

Personally written content.

Dedication

Personally written text

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List of Tables

Table 1. List of Reviewed Articles 51

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Table of Contents

Acknowledgments iii

List of Tables v

CHAPTER 1. INTRODUCTION 1

Background of the Problem 2

Statement of the Problem 2

Research Question 2

Significance of the Study 3

CHAPTER 2. LITERATURE REVIEW 5

Patients' Satisfaction and Preference for Telehealth Visits 5

Virtual Visits and Patient-Centered Care 6

Patient and Caregivers' Satisfaction with Telehealth 6

Home Telehealth, Patient Satisfaction, Functions and Challenges 7

Military Health System Access to Care: Performance and Perceptions 8

Telehealth and Patient Satisfaction:

A Systematic Review and Narrative Analysis 9

Acceptability and Cost-Effectiveness of

Military Telehealth Mental Health Screening 10

Telemedical Support for Military Medicine 11

Telehealth: Reducing 30-Day Hospital Readmissions

Among Health Failure Patients 12

Virtual Clinic in General Surgery Patients 12

Virtual Visits for Follow-Up Stroke Care 13

Virtual Visits for Acute, Nonurgent Care 13

Virtual vs. Traditional Consults 14

Practice-Based vs. Telemedicine Based: Care for Depression 14

Managing Hypertension in Urban Underserved Subjects Using Telemedicine 15

Telehealth in the Developing World 16

Telemedicine During COVID 19 Pandemic- Western China 16

Virtual Rheumatology Appointments During COVID-19 Pandemic 17

Perception of Telehealth 18

Telehealth in Health Centers 19

Barriers to Participation and Adoption of Telehealth and Telecare 20

Telehealth in Overcoming Barriers in Licensure and Improve Access to Care 21

Crossing the Telemedicine Chasm: U.S. Barriers to

Adoption of Telemedicine Reduced? 21

Cost of Telemedicine in Diabetes Education 22

Telehealth in Veterans Affairs Mental Health Care 23

CHAPTER 3. METHODOLOGY 24

Introduction 24

Research Question 24

Instrumentation 24

Ethical Considerations 25

CHAPTER 4. DATA COLLECTION, ANALYSIS AND RESULTS 26

Introduction 26

Data Collection Procedures 26

Data Analysis and Results 27

Pre-COVID-19 Pandemic 27

During COVID-19 Pandemic 29

CHAPTER 5. CONCLUSIONS AND RECOMMENDATIONS 32

Introduction 32

Limitations 35

Conclusions 35

Recommendations for Further Study 36

REFERENCES 37

APPENDIX A: ARTICLE SELECTION PROCESS 50

APPENDIX B. SYSTEMATIC LITERATURE REVIEW 51

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CHAPTER 1. INTRODUCTION

The face of healthcare is fast changing, brought by new technological developments not just with hospital equipment, medical techniques, and pharmacology, but with the advances in communication modes as well. Telehealth services have never been more essential than now (CDC, 2020). Healthcare professionals and health systems need to treat their patients from a distance and securely collaborate with colleagues in real-time (McMahon & Duncan, n.d.). The number of telemedicine consultations reached a 700 percent increase in 2015, and 77 percent of consumers say they would be more likely to choose a doctor who offers telehealth than those who are not using the technology (McMahon & Duncan, n.d.). 

In the military, the Defense Health Agency (DHA), which governs the healthcare system, recently sought to expedite the process of aggressive utilization of telehealth due to the urgency to continue providing care and maintaining access to care during the pandemic (MHS, 2020b). The agency put out three significant changes to impact the need for access while preventing direct-contact patient care; (1) audio-only telephone visits with providers, (2) incentivizing network providers telehealth, and (3) waiving of cost-share for telehealth users (MHS, 2020b).

During the recent pandemic, the Center for Disease Control and Prevention suggests changes to health care delivery are needed to reduce staff exposure to infected persons, preserve personal protective equipment (PPE), and minimize the impact of patient influx on facilities. Furthermore, telehealth services can provide these necessary care and precautions to prevent the spread of SARS-CoV-2, the virus that causes COVID-19. Telehealth services can be used for COVID-19 screening, low-risk urgent care, primary care, specialists access, patient coaching and support, physical and occupational therapy sessions, monitoring patients with chronic medical problems, case management, and follow-up care (CDC, 2020).

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Background of the Problem

Access to care is only one factor in measuring patient satisfaction in any health system (MHS, 2020a). Patients may perceive poor access to care due to many factors, including parking or distance from the entrance of the facility to the clinics and long lead time between a schedule is made and the actual appointment (Mayo Clinic, 2020). Access is also an issue that remote areas have been facing for many years, brought by distance and lack of medical providers to manage the care of the local population. In the military, healthcare providers are civilian government employees, civilian contracts, and military personnel, and typically, military health care professionals change duty stations every two or three years (Abiero et al., 2020). Hence, access to care and patient satisfaction become pressing issues in times like these. The options are to transfer the patients to the civilians and contract providers or refer patients to a network provider (Kellerman, 2017).

Statement of the Problem

The world's eventful situation changed how people seek medical care. During the COVID-19 pandemic, the need to utilize telehealth in a much larger and robust capacity was initiated. It will be worth studying the effectiveness of telehealth/telemedicine as an answer to access to care shortages and to promote positive experiences to patients during the COVID-19 pandemic and maybe in the future.

Research Question

This project will answer the following research questions: How effective is Telehealth/Telemedicine in addressing access to care problems and increasing patient satisfaction before, during, and maybe after the pandemic? What are the possible barriers and other benefits it brings to health care systems?

Significance of the Study

Healthcare professionals use telemedicine/telehealth to evaluate, diagnose, and treat patients without a face-to-face visit in the clinic. It is a two-way communication system between a physician and patient that is frequently used for follow-up visits, medication management, consultation, management of chronic conditions, and a wide array of other clinical services (Mayo Clinic, 2020). Kruse et al. (2017) and Polinski et al. (2016) both showed in their studies that the telehealth system could optimize access to care and increase patient satisfaction. During a pandemic such as COVID-19, where the safety of each individual is at stake, virtual appointments are crucial to address the routine medical needs of the people (CDC, 2020).

Telehealth is a tool that uses technology to provide health care and other health-related services remotely. Though it does not increase the size of the provider workforce nor a service itself, telehealth is a mechanism for delivering health care services that can help increase efficiency and extend the reach of existing providers (Mayo Clinic, 2020). This includes communication and education between providers and between patients and providers (Mayo Clinic, 2020). At the same time, telemedicine is the practice of medicine using technology to deliver care at a distance where a physician in one location uses a telecommunications infrastructure to provide care to a patient at a distant site (Mayo Clinic, 2020).

In the US military, since 1992, telehealth and telemedicine have emerged as valuable components of the Military Health System (MHS) in both garrison and deployed settings (Schulder Rheuban & Krupinski, 2018). The MHS has a worldwide mission of supporting active duty service members, retirees, and their beneficiaries in peacetime health care needs, including the continental United States, and deployed active duty service members and retirees outside the continental United States (Schulder Rheuban & Krupinski, 2018). Embedded in the 2017 National Defense Authorization Act (NDAA), it stated the universal use of telehealth in various military settings (Kellerman, 2017). The military health system uses as a platform of support to health care providers working in small forward operating bases and on ships at sea (Kellerman, 2017). Despite the successful deployment of telehealth overseas and in the civilian sectors, the military health system was slow to adopt it at home due to stringent information security requirements and budgetary constraints (Kellerman, 2017). However, 2017 NDAA directs the military health system to rapidly expand telehealth in its clinical operations (Kellerman, 2017).

CHAPTER 2. LITERATURE REVIEW

Patients' Satisfaction and Preference for Telehealth Visits

According to Polinski et al. (2016), a quarter of patients in the United States do not have a primary care provider or do not have complete access to one. Their work and personal responsibilities affect their capabilities to find convenient and accessible care. Telehealth services facilitate patients' access to care, but whether patients are satisfied with telehealth is unclear (Polinski et al., 2016).

Polinski et al. (2016) conducted a study comparing face-to-face visits and telehealth visits in eleven clinics in Texas and California to measure patient satisfaction. With 1,734 telehealth patients surveyed, 32% expressed a preference for receiving care via telehealth. An additional 57% rated a telehealth visit as just as good as a traditional visit, while only 1% of patients rated the telehealth visit as worse than a traditional visit (Polinski et al., 2016). Additionally, over half of patients expressed shorter to no wait time as their primary motivation for using telehealth, 95% of all patients were very satisfied, 98% rated the assisting nurse as highly capable, and 94 % were very satisfied with the treatment plan and educational materials they received (Polinski et al., 2016).

This study strongly supports that many patients would prefer using telehealth. According to Polinski et al. (2016), patients who were very satisfied with telehealth appointments, quality of care, and convenience had more than 2.3 times the odds of liking telehealth. These results provide insights into patients' motivations for using telehealth and factors associated with their preference for telehealth visits (Polinski et al., 2016).

Virtual Visits and Patient-Centered Care

While the use of virtual visits is growing rapidly, several health systems are integrating virtual visits into primary care to complement existing modes of care, in part reflecting a growing focus on patient-centered care (McGrail et al., 2017). McGrail et al. (2017) conducted a study to describe the patients' and providers' virtual visits and explain why patients use virtual care. In the study, during 2013-2014, there were 7,286 virtual visit encounters observed, involving 5,441 patients and 144 physicians. It was found that the 399 virtual visits indicated that patients liked virtual visits; with 372 (93.2%) responded that their virtual visit was of high quality; and 364 (91.2%) reported their virtual visit was "very" or "somewhat" helpful to resolve their health issue. 

The number of virtual visits continues to increase to complement and provide a new way for patients and providers with existing relationships to interact (McGrail et al., 2017). Other important reasons for the use of telehealth are easing access and providing patients with needed care at a convenient point in time, but not necessarily displacing subsequent service use (McGrail et al., 2017). McGrail et al. (2017) mentioned that a patient-centered system is organized to respond to patient needs without these unintended side effects. Virtual visits may be one way the system can be refocused. Additionally, it is essential to consider how technologies are integrated into the system to support the existing relationships or simply another way to see a provider as needed (McGrail et al., 2017). This study supports that telehealth is an excellent way to satisfy the medical needs of patients.

Patient and Caregivers' Satisfaction with Telehealth

Telehealth is an alternative method of delivering health care to people required to travel long distances for routine health care (Orlando et al., 2019). Population in rural and remote areas are generally satisfied with telehealth as a mode of service delivery because of improved access to care and convenience. Orlando et al. (2019) conducted a systematic examination of whether patients and their caregivers living in rural and remote areas are satisfied with telehealth videoconferencing as a mode of service delivery in managing their health.

According to Orlando et al. (2019), patient satisfaction is essential for telehealth to be a viable mode of service delivery. One criterion observed in the study was system experience, which was the most commonly measured dimension of satisfaction appearing in 29 studies (81%). It was also found that there were high satisfaction levels concerning service accessibility in telehealth. Furthermore, there is consistent evidence that telehealth has an overall positive impact on patient and caregivers' satisfaction highlighting that distance may no longer be a barrier, especially in rural and remote areas (Orlando et al., 2019). According to the researchers, consumer focus should not be compromised with the advances in information and communication technologies; but rather improve the functional delivery of telehealth. Since this study was focused mainly on a specific population, rural and remote areas, it is found that telehealth, such as video conferencing, is an essential mode of healthcare delivery. However, while telehealth is not a replacement for face-to-face appointments, an alternative method of healthcare delivery that, when integrated into an established service, could form part of patients’ choice when clinically safe and appropriate. Aligning a health care service with patients' expectations and needs can lead to overall patient satisfaction (Orlando et al., 2019).

Home Telehealth, Patient Satisfaction, Functions and Challenges

To support the needs of the aging U.S. population, Congress and the U.S. Department of Veterans Affairs (V.A.) prioritized the noninstitutionalized care services with The Veterans Millennium Health Care and Benefits Act of 1999 (Young et al., 2011). The program is known as the care coordination/home telehealth (CCHT), established in 2003. Home telehealth programs can enhance older adults' access to care, but gathering accurate information regarding the program's effectiveness is challenging because patients can be reluctant to provide criticisms (Young et al., 2011).

There are three common elements of CCHT, the care coordinator (CC), the telehealth technology, and the patient (Young et al., 2011). The home telehealth technology, which involves messaging devices, monitoring and measuring devices, videophones, or personal computers, is used depending on the needs and capabilities of the patient. At the same time, the CC is usually a registered nurse. The study demonstrated that home telehealth holds value not only for providers but also for patients. The patients are more involved with their care because they learn more about their condition and are better monitored. With the expansion of home telehealth programs, enrollment increases, the scope of health issues being addressed, and tracking the program functionality becomes increasingly important and challenging. Despite the challenge, it was found that 98% of the surveyed individuals indicated that they were extremely satisfied with CCHT. Although the study involves more than one mode of telehealth, it provides the fact that telehealth has a positive effect on healthcare management. Lastly, addressing equipment failures and patient frustrations with connection accessibility, the successful expansion of telehealth is more likely (Young et al., 2011).

Military Health System Access to Care: Performance and Perceptions

Like in other healthcare systems, access to care in the military is an essential component in providing high-quality healthcare. According to Abiero et al. (2020), in the Military Health System (MHS), access to care (ATC) is essential not only for ensuring the health and well-being of MHS beneficiaries but also for ensuring the medical readiness of active-duty personnel. They conducted a study to examine the relationship between ATC administrative data and patient survey results. The Joint Outpatient Experience Survey (JOES) and administrative data were collected from the Military Health System Data Repository from May 2016 through March 2017 for 135 parent Military Treatment Facilities (MTF) (Abiero et al., 2020).

The JOES can help diagnose potential access issues, which involve call center scheduling and provider availability (Abiero et al., 2020). In the study, researchers have found that as the wait time for appointments increases, patients' ratings of the time between scheduling and appointment dates decline, and patients' assessments of being able to see a provider decline as well. Additionally, the study suggested exploring the gaps in looking into best practices at facilities with high patient experience with access and looking at other survey measures related to access, such as telephone resources and web-based communication programs. Finally, patients may perceive poor access to care due to many factors, including parking or distance from the entrance of the facility to the clinics and long lead time between the date an appointment was made and the actual appointment (Abiero et al., 2020). Although not directly mentioned anything about telehealth, it strongly suggested seeking best practices to address the access to care issues.

Telehealth and Patient Satisfaction: A Systematic Review and Narrative Analysis

Telehealth is a viable platform to deliver quality patient care that meets high patient satisfaction. Kruse et al. (2018) performed a systematic review and narrative analysis to explore the association of telehealth and patient satisfaction regarding effectiveness and efficiency. The study found that 20% of the articles showed improved outcomes, 10% as preferred modality, 9% as ease of use, 8% as low cost, 8% as improved communication, and 7% as decreased travel time, which accounted for 61% of occurrences. The authors stated that telehealth is feasible for providers who want to expand their practices to remote areas without relocating or expanding their practice footprint. Additionally, telehealth was identified to have the potential to extend the boundaries of providers' practices by overcoming the barrier of proximity.

Acceptability and Cost-Effectiveness of Military Telehealth Mental Health Screening

Jones et al. (2012) pointed out that telehealth has been identified as addressing the military shortage of mental health providers. Hence, no research supports the viability of mental telehealth care for the population on mental health screening as a standard component of post-deployment medical screening. Jones et al. (2012) conducted a study that summarizes soldier perceptions of three separate screening events in which telehealth was used and the cost-effectiveness of telehealth versus in-person implementations of the same screening such as; (1) soldiers who have not been through telehealth screening report a strong preference for in-person screening; (2) soldiers who have been through telehealth screening still report a preference for in-person screening, but they express more ambivalence about the screening method; and (3) using telehealth-only mental health screening for large numbers of soldiers within a compressed time frame is more expensive than in-person screening.

Although findings suggest that in-person interviews are more efficient than telehealth interviews because of the increased difficulty of long-distance coordination with telehealth, there is a meager refusal rate of 7% for those subjected to VTC visits. At the time of this study, while at an early stage of consideration of telehealth as an option, there is a sign of improved understanding of the costs and acceptability; the military and government leaders are off to a good start to provide an alternative post-deployment care to our service members (Jones et al., 2012).

Telemedical Support for Military Medicine

To sustain the mission of deployed units of the U.S. military, especially in the Iraq and Afghanistan areas of operations (A.O.), the healthcare system needs new ways to ensure proper and timely care to casualties within the "Golden Hour" to life-saving surgical care. Nettesheim et al. (2018) identified telemedicine as one solution that can aid in this environment because it can reduce the medical footprint in a theater of operation by bringing the remote expert's knowledge and experience to the point of need. It can augment the capabilities of caregivers in austere operational settings using available communication technologies to optimize the care of casualties who are delayed in evacuation to higher levels of care (Nettesheim et al., 2018).

Nettesheim et al. (2018) conducted a systematic historical review of literature about military telemedicine. The researchers pointed out that Military telemedicine is currently focused on providing specialty care to general medical caregivers such as physicians, physician assistants, independent duty corpsmen, and special operations medics, when distance, time, and operational requirements make doctrinal evacuation guidelines or routine medical evaluation is impractical (Nettesheim et al., 2018). Telemedicine, notably VTC used to support direct patient care or procedural mentoring, which requires significant bandwidth and minimal latency and jitter. According to Nettesheim et al. (2018), with the continuous development of new technologies arise in the field of telemedicine, they can never replace the necessity of training and nurturing the experience of deployed clinicians and remote consultants. Ensuring telemedicine is used by appropriately trained personnel is paramount to its success and optimizing casualty care in the future. This study proves that there are other areas where telemedicine or telehealth can be helpful and valuable.

Telehealth: Reducing 30-Day Hospital Readmissions Among Health Failure Patients

This study looked at telehealth as one strategy to reduce 30-day hospital readmission for heart failure patients. Telehealth programs were used to provide a wireless computer-based reporting system (tablet) that collects patient vital signs (i.e., weight, heart rate, blood pressure, and blood oxygenation) via wireless peripherals, and

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