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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 132-137

Patient perspective on telehealth during the COVID-19 pandemic at the cardiology outpatient clinic: Data from a qualitative study


1 Department of Medical and Clinical Psychology, Tilburg University, Eindhoven, The Netherlands
2 Department of Communication and Cognition, Tilburg University; Philips Research, Eindhoven, The Netherlands
3 Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands

Date of Submission05-Jul-2021
Date of Acceptance27-Sep-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Mirela Habibovic
Department of Medical and Clinical Psychology, Tilburg University, Tilburg
The Netherlands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_39_21

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  Abstract 

Background: Within the field of cardiology, telehealth has been advocated by many as important benefits have been demonstrated regarding disease management and survival. Both patient- and physician-related barriers have hampered the uptake of telehealth in the clinical practice. The COVID-19 pandemic has pushed the upscaling of telehealth modalities. Objective: The current study will examine patients' preferences, needs, and recommendations regarding the use of telehealth at the cardiology outpatient clinic during the pandemic. Methods: Semi-structured focus groups were organized covering two themes: (1) patients' experiences with telehealth and (2) patients' needs and recommendations regarding the use of telehealth. Focus groups were held online using Microsoft Teams, and audio recordings were made. After transcribing the recordings, thematic analysis was applied to code the answers that were given. Results: A total of n = 19 patients were recruited; the mean age was 62.4 (7.7) and 10 (52.6%) were female. The majority of the patients (15/19) indicated to be positive regarding telehealth use mainly due to its time-saving character. Four patients were negative toward telehealth as they did not receive appropriate care in their perception due to telehealth use. Patients recommend using blended care where teleconsultation, and face-to-face appointments are provided in accordance with patients' preferences. Conclusions: This is the first study to examine, in-depth, cardiac patients' experiences, needs, and recommendations regarding telehealth use in the clinical practice. Learning from current experiences with the COVID-19 pandemic where upscaling of telehealth emerged will give us a foundation to further increase the uptake of telehealth in the clinical practice.

Keywords: Cardiovascular disease, e-health, m-health, patient perspective, telehealth


How to cite this article:
Habibovic M, Kraaij CM, Pauws S, G. Widdershoven JW. Patient perspective on telehealth during the COVID-19 pandemic at the cardiology outpatient clinic: Data from a qualitative study. Heart Mind 2021;5:132-7

How to cite this URL:
Habibovic M, Kraaij CM, Pauws S, G. Widdershoven JW. Patient perspective on telehealth during the COVID-19 pandemic at the cardiology outpatient clinic: Data from a qualitative study. Heart Mind [serial online] 2021 [cited 2022 Nov 27];5:132-7. Available from: http://www.heartmindjournal.org/text.asp?2021/5/4/132/331563


  Introduction Top


Over the past years, our health-care system has faced great challenges in health-care provision due to the increase in life expectancy and shortage of physicians and nurses.[1] Within the field of cardiology, care virtualization by means of telehealth, e-health, and m-health has been advocated as a promising modality to support/improve health-care services (e.g., prevention through lifestyle management, disease management, heart rhythm monitoring, and telerehabilitation) and health-related outcomes[1],[2],[3],[4],[5] in future. Hence, the use of e-health modalities in the standard health-care models is increasingly being adopted worldwide. For example, in Germany as of 2020, the doctors can prescribe validated digital health applications to their patients (Digitale-Verzorgung-Gezets, 2019). In the United States of America, the Centers for Medicare and Medicaid Services (CMS) support telehealth implementations by providing reimbursement for online-only consults. Furthermore, in China, telehealth has become a part of the standard medical care, reimbursed by health insurance companies, and covers (among others) disease management, patient management, digital pharmacy, and physician support apps. Despite the increasing experience with telehealth and previous recommendations, large-scale deployment of telehealth in the cardiology practice has been hampered due to physician (legal and ethical issues, lack of interoperability between systems, limited large-scale evidence, and reimbursement issues) and patient (privacy and security and quality issues, user characteristics and health status, and lack of motivation) related barriers[1],[5],[6],[7] and lack of collaboration between different stakeholders (e.g., patients, health-care providers, developers, and insurance companies).[8],[9]

In March 2020, the World Health Organization characterized the emergence of the COVID-19 virus as a pandemic.[10] The increasing numbers of hospitalizations that were associated with COVID-19 infection have subsequently increased the pressure on health-care systems worldwide[11] pushing rapid changes in health-care services.[12] One of these changes was the adoption of telehealth services[13] which have served to (1) improve COVID-19 patient care,[14] (2) safeguard continuation of routine care for other conditions such as cardiovascular disease.[15] Despite the aforementioned barriers to care virtualization uptake,[1],[9] all stakeholders had to rapidly adapt to the new telehealth care models[12],[13],[15],[16] as this was the safest option to provide health care during the pandemic.

The upscaling of telehealth has highlighted its numerous benefits (e.g., increased health access, reducing in-hospital visits, and medication management) which could prevail in the postpandemic health-care system.[15],[17],[18] Hence, for various conditions, the use of telehealth modalities has been advocated or implemented during the COVID-19 pandemic (e.g., dermatology, primary care, and urological cancer).[19],[20],[21]

To form a good foundation for telehealth implementation and increase the uptake of this modality after the COVID-19 crisis, it is important to understand the experiences, needs, and preferences of the end users that were part of these rapid health-care system changes.[17] However, an in-depth understanding of patients' needs and preference regarding telehealth use is lacking. In their study of telehealth consultation in general practice during the lockdown in March, Imlach et al.[22] showed that telehealth was not suitable for all patients but that the majority of patients perceived telehealth as convenient and reported high satisfaction.[22] A recent viewpoint by Reeves et al. stated that telehealth use should be tailored to patient's characteristics, visit type, chief complaint, and disease state.[18] Within the cardiac population studies showed that particularly related to disease management and remote monitoring, the majority of patients foresees benefits of telehealth.[8],[23] However, patient-related characteristics such as older age and lower socioeconomic status may be important barriers to telehealth uptake.[6],[24] To increase the uptake of telehealth in the future, it is important to gain more insight in the patient perspective on telehealth and identify the possible facilitators and barriers.[25]

Hence, the current qualitative study will examine the experiences, needs, and preferences of patients who have received telehealth care at the cardiac outpatient clinic during the COVID-19 pandemic.


  Methods Top


Procedure

Cardiac patients (coronary heart disease, heart failure, and arrhythmias) were contacted by telephone and approached for participation by a research assistant. Patients who indicated being positive toward participation received an e-mail containing a link to the patient information and informed consent. Patients were requested to sign the informed consent in a Qualtrics© survey. If participation was not confirmed/declined within 1 week, patients were contacted again by telephone and reminded to indicate participation preference.

After signing the informed consent, patients received a confirmation e-mail and instructions for using Microsoft Teams where the focus groups were organized. One or two days before the meeting, patients received the link to the meeting.

Declaration of ethical approval and patient consent

The study was approved by the local Ethics committee of the Elisabeth-TweeSteden Hospital and by Tilburg University Ethics board (L1038.2020/NW2020-54) on 10 August 2020. All patients signed informed consent before participating in the focus group.

After the meeting, patients were sent a 20-euro worth gift card by E-mail.

Study outline

The current study is a part of the ongoing telehealth study (AFSTAND) where patient perspective on telehealth during the COVID-19 pandemic is examined. Five semi-structured focus groups each with 5–6 patients were organized to discuss (1) patient's experience with received telehealth and (2) recommendations regarding the implementation of telehealth in the future. Due to the COVID-19 measures, the focus groups were performed online, using Microsoft Teams, by the authors (MH and CK).

The focus group started with a short introduction, in which the rules regarding privacy and interaction with each other in a respectful way were explained by the moderator. If all patients agreed, the focus group was recorded.

The focus groups were audiorecorded, and notes were taken by the authors (MH and CH). The recordings were transcribed by CK after the sessions. After the transcripts were made and additional notes from MH and CK were added to the document, MH categorized the answers using thematic analysis. Answers were coded based on the predefined, semi-structured focus-group protocol themes as mentioned previously. In addition, MH and CK quantified how often the same answers (in case of closed-ended questions) were given by the participants. Participants were asked to grade the last teleconsultation on a scale from 0 to 10 by answering the question “How satisfied are you with the last teleconsultation received at the cardiology outpatient clinic.” The mean score was calculated and represented satisfaction with the last teleconsultation.

Inclusion and exclusion criteria

Patients who have had a telephone consultation during the COVID-19 pandemic between August 2020 and December 2020 at the cardiology outpatient clinic at Elisabeth-TweeSteden hospital were approached for participation.

Patients who were older than 75 years, not mastering the Dutch language, had a life expectancy <1 year, had life-threatening comorbidities, or patients who were experiencing or who had a history with a psychiatric illness (other than anxiety and depression) were not approached for participation.


  Results Top


Sample characteristics

A total of n = 77 patients were contacted by telephone and approached for participation. Forty patients indicated not to be available due to work or other appointments and lack of solid internet connection. Hence, n = 37 patients indicated to be interested and were provided with study information in writing (online). Of these, patients eventually n = 19 consented to participate. Five focus groups (number of patients per group varied between n = 3–5) were performed with these patients. The mean age of the sample was 62.4 (SD = 7.7) with n = 9 (47%) of the sample being male. Patient characteristics are displayed in [Table 1]. All patients indicated having a telephone-based consultation with a cardiologist one or two times in the past 3 months. This was the only type of telehealth that was reported. One patient indicated sending ECG recordings to the cardiologist (recorded with smartphone) to evaluate for the possible rhythm disturbance, and one patient monitored blood pressure mainly for own insight unrelated to cardiac condition and shared this with the cardiologist. Both patients did this on their own initiative, the ECG and blood pressure monitoring was not required as a part of teleconsultation.
Table 1: Patient characteristics

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Patients' experiences with telehealth

To get insight in patients' general satisfaction about their last teleconsultations, they were asked to indicate how satisfied they were overall about the consultation. Patients graded the last telehealth consultation that they have received with a mean of 7.1 (on the scale of 0–10).

Positive perspective on telehealth

Eleven (11/19) patients indicated to be positive about telehealth and that they would like to see telehealth to be implemented also in the postpandemic health-care system. The main reasons for a positive attitude toward telehealth were that it saves travel and waiting time during the visit and that it was possible to schedule an appointment with their cardiologist on a relatively short notice.

“I think it is a great way to get the care I need without the travel burden….it saves a lot of time….maybe if I lived very close to the hospital, I would prefer face-to-face appointments….but still….this would be more efficient (translated from Dutch).”

Patients indicated that this was an efficient way of receiving care “It saves time for me and the health care provider.” Particularly, if it concerns only checking the medication or getting results from blood tests. One of these 11 patients indicated to be particularly happy with this new development as a high burden was experienced when visiting the hospital. It was very inconvenient for the patient to travel due to a medical condition. Telehealth contributed significantly to the reduction of patients' travel-related burden.

Three (3/19) patients experienced telehealth as acceptable but perceived it as less appealing compared to face-to-face care. They indicated that it was a pity that they could not see their cardiologist, this created emotional distance between the health-care provider and the patient. One patient indicated not being able to share everything that she wanted with the health-care provider. During a face-to-face appointment, more information is shared as one patient indicated:

“After the telehealth consultation, I always think 'ah I should have said that….' I always forget to say things that I wanted to say (translated from Dutch).”

Finally, one additional patient (1/19) said to be satisfied but indicated that it would have been helpful to have the possibility to share pictures with the health-care provider during the telephone consultation. This patient said:

“….an appointment was scheduled to evaluate the healing of my pacemaker wound….there was no possibility of sharing pictures of the wound/stiches….I had to describe to the cardiologist how it looked……it would have been much easier if I could send him a picture and then have the telephone consultation (translated from Dutch).

Negative perspective on telehealth

Four patients (4/19) had a negative view toward telehealth. Two patients (2/4) indicated that they did not receive the care as needed on time. In patients' perception, the care was delayed because it was not possible to assess the symptoms correctly with teleconsultation, and visiting the doctor (face to face) was not perceived necessary by the cardiologist (after teleconsultation). One of the patients indicated that a face-to-face consultation would have probably resulted in a different outcome, the patient stated:

It felt like I was kept on a distance (translated from Dutch).

Another patient (1/4) said that in her case, a delay in searching for care occurred because of her own attitude toward telehealth.

Things don't feel urgent enough to call your cardiologist, a face-to-face appointment would be much easier (translated from Dutch).

This patient also stated that during face-to-face consultation, it is much easier to talk to the cardiologist, “you are more likely to share more information.”

This was also recognized by another patient who felt more inhibited and insecure during a telephone consult as compared to face to face.

Finally, six (6/19) patients indicated that telehealth reflects a downgrading of our social interaction and communication which might lead to lower health-care quality and satisfaction.

Recommendations for future telehealth practice

The majority (n = 14) of the participants think that telehealth is useful and could be implemented in future health care (even after the COVID-19 pandemic). However, the important factors should be taken into account such that the quality of care is warranted. Particularly, the patients indicate that telehealth should not replace face-to-face contact with the physician as this is pivotal to provide good quality care. Face-to-face appointments should be scheduled, for example, once every two teleconsultations.

All but one participant indicated the following preference regarding consulting a physician:

  1. Face-to-face consultation
  2. Video call consultation
  3. Telephone consultation


The face-to-face consultation was considered particularly important in the case of a first consultation (when meeting the cardiologist) and when discussing a diagnosis or important treatment (follow-up). Establishing a good relationship with the cardiologist was perceived as very important for future consultations. If this relationship is positive, “you can trust your cardiologist and information sharing won't be much affected by telehealth use,” telehealth would also be much more acceptable for the following appointments.

Not only depending on the type of consultation (diagnosis and regular checkup) but also depending on the disease severity, the health-care provider should consult the patient to discuss which type of consultation is preferable. If a serious event has happened or important treatment decisions have to be made, this should be discussed face-to-face at any time.

It was also indicated that satisfaction with telehealth should be explicitly checked with the patient (directly after the consultation), and then the option to meet face-to-face should be offered.

One of the patients raised the concern regarding patient's privacy of communicating through telehealth. It was advocated that telehealth communication channels should be safe and secure and if possible integrated with existing hospital systems such as the patient portal.

All patients agreed that when the telehealth consultation is scheduled a precise time slot (of 1 h if possible) should be indicated.

“I was informed by the hospital that the cardiologist would call me on Friday morning….so I could not schedule anything in the morning….he called around noon….my whole morning was wasted on waiting for a call…(translated from Dutch).”

“If the time slots are not precise than the time-saving benefits of telehealth sort of disappear (translated from Dutch).”

Use of devices and patient portal

All patients (19/19) were positive regarding the use of devices to monitor their vital signs and to share this with their cardiologists. It was noted that this information should contribute to a better prognosis of their disease and that the cardiologist should actually use this data to improve their treatment if possible. Two (2/19) patients indicated that collecting additional data and sharing it with the cardiologist is only useful if the cardiologist would review it regularly. During an appointment, “I would feel like taken more serious if the cardiologist would discuss the data that I shared with him.” Collecting and sharing data regarding lifestyle variables that are not strictly related to the cardiac disease was not perceived as useful by the majority (17/19), and the patients would not consider sharing this actively with their cardiologist without indication.

All patients (19/19) are aware of the patient portal at their local hospital (MijnETZ) and know that they can access their medical chart there and communicate with the cardiologist. Fourteen patients (14/19) use the patient portal to check test results (n = 14), to communicate with the cardiologist (n = 3), to check the appointment dates (n = 14), and to check the medication (n = 2). Although the patient portal is perceived as a safe and secure modality, all patients (19/19) prefer to share their medical information during face-to-face encounters with the cardiologist. They are reluctant to whether the information (when shared through the portal) will be correctly stored and communicated to the health-care provider.


  Discussion Top


To our best knowledge, this is the first study to examine the experiences, needs, and preferences of cardiac outpatients who received telehealth care during the COVID-19 pandemic. Our results showed that telephone consultation was the only telehealth modality that was used during the past year. In general, patients perceived telehealth as useful; however, important recommendations for future implementation of telehealth were outlined and serious concerns were raised such as late diagnosis, not feeling able to share all information with the cardiologist, downgrading of social interaction, and privacy issues. To increase the acceptability of telehealth, patients preferred video consultation over telephone. The results also showed that the acceptability of telehealth depends on the type and reason of consultation, disease status, and established relationship with the cardiologist. The results further showed that patients are willing to use monitoring devices that will aid the diagnosis and/or management of their cardiac condition. However, the data from these devices should be closely monitored by the cardiologist; otherwise patients indicated that they would not feel taken seriously. Finally, all patients were aware of the existence of a patient portal, and the majority used it to either communicate with the cardiologist or review their own medical/appointment data.

The current findings are in line with the previous studies showing that patients foresee benefits of telehealth application in the clinical practice[8],[22],[26] while also pointing out important concerns such as privacy issues and lack of social interaction.[7] Furthermore, in line with the previous studies, our data show that type of consultation is one of the leading factors determining the acceptability of telehealth.[18] Finally, the general acceptability of using telehealth devices is in line with our previous findings[27] where a large adherence and acceptability among cardiac patients was observed.

Based on our findings and previous (also pre-pandemic) studies, it appears that cardiac patients perceive telehealth as a useful modality to receive (certain types of) care. Particularly, routine follow-up consultation and routine care could be provided using telehealth, as previously advocated.[13],[16],[22] While the patients are ready to engage in using telehealth modalities, the clinical practice seems to lag in this development as telehealth, e-health, and m-health are not sufficiently implemented in the daily practice.[18] This has possibly to do with both physician-related burden and as the lack of communication between important stakeholders.[7],[12] In addition, important privacy and security issues, as well as care reimbursement adaptations have to be made to implement telehealth as a part of the standard care. Finally, significant reorganizations of the health care system would have to be realized.[3]

While taking possible downsides of telehealth implementation (e.g., not being suitable for all patients) into account, it is important to note that the wireless network coverage is high and that there is thus the possibility of reaching large groups and underserved groups of people to provide care to.[1] Furthermore, within the cardiac patient population telehealth solutions could contribute to better diagnosis and management of multiple conditions[1],[2],[3],[4],[5] and subsequently even reduce mortality and hospitalization rates in certain subgroups.[28],[29]

As care virtualization is the step forward in improving health outcomes of many, it is important to focus on understanding what the needs and preferences of the patients are and tailor the care to these needs as much as possible.[17] This could be realized by including the patients in the development of new telehealth modalities and evaluating their experiences and perceived benefits on a regular basis.[7] Furthermore, as all patients are familiar with patient portals and access them on a regular base, the portals could play an important role in telehealth adaptation. Increasing interoperability between ICT systems by, for example, integrating monitoring devices with the patient portal and videoconsultation technology could be a step forward to provide telehealth that is perceived as safe and reliable.

To further reduce the physician burden, it is important to conduct large-scale studies to evaluate the effectiveness/benefits of telehealth use in relation to health outcomes. In addition, reimbursement of telehealth consultations/modalities should become part of the standard care models for it to be upscaled.

The results of our study should be interpreted in light of the study limitations. First, the study covers a heterogeneous cardiac population which makes it difficult to determine for which cardiac condition telehealth is more (or less) applicable. Second, telehealth in our sample refers only to telephone consultations. The results might have been different if other telehealth modalities were included. However, from previous studies on heart failure patients, the results are comparable.[23] Third, the sample is relatively small; however, data saturation was reached during the study. Finally, the pandemic might have affected patients' perception on telehealth use (made it more favorable) and thus affected the current findings. However, we were able to recruit equal numbers of male and female patients in our sample and represent the views of both genders. In addition, we captured the experiences, preferences, and recommendations of cardiac patients in a real-life setting where upscaling of telehealth was pushed due to the pandemic. From these insights, we are able to learn how to develop a good foundation for future implementation of telehealth in the health care system and optimize the uptake. Telehealth could resolve a confounding situation like the COVID-19 pandemic where in-hospital visits are discouraged. Using telehealth routing care could be continued and adverse health outcomes could be prevented.[30]


  Conclusions Top


The current findings indicate that the majority of patients are overall satisfied with telehealth consultation and that they would like to see telehealth implemented in the clinical practice. However, during this process, patients' preferences regarding receiving telehealth care (when, where, and how) should be monitored, and the establishment of a good relationship with the cardiologist is pivotal. While the patients seem to be ready for telehealth, it is up to health care professionals/health-care system to organize the provision of care using telehealth and apply telehealth modalities more in the clinical practice.

Acknowledgments

We would like to thank the patients for participating in the focus groups and sharing their experiences with us. We would like to thank the student assistants Elien Blaauw and Annabel Boeckhout for patient recruitment during the study.

Financial support and sponsorship

The study was funded by Tilburg University Herbert Simon Research Institute with a grant awarded to Dr. M. Habibović and Prof. Dr. J. Widdershoven.

Conflicts of interest

There are no conflicts of interest.



 
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