BACKGROUND
Since the COVID-19 pandemic, telemedicine appointments have replaced many in-person healthcare visits [1 2]. However, older people are less likely to participate in telemedicine, preferring either in-person care or foregoing care altogether [3-6]. With a high prevalence of chronic conditions and vulnerability to COVID-19 morbidity and mortality through exposure to others in health care environments, (1-4), promoting telemedicine use should be a high priority for seniors. Seniors face significant barriers to participation in telemedicine, including lower internet and device access and skills, and visual, auditory, and tactile difficulties with telemedicine.
OBJECTIVE
Hoping to offer training to increase telemedicine use, we undertook a quality improvement survey to identify barriers to, and facilitators of telemedicine among seniors presenting to an outpatient family medicine teaching clinic which serves predominantly African American, economically disadvantaged adults with chronic illness in Cleveland, Ohio.
METHODS
Our survey, designated by the IRB as quality improvement, was designed based on a review of the literature, and input from our primary care providers and a digital equity expert (Figure 1). To minimize patient burden, the survey was limited to 10 questions. Because we were interested in technology barriers, data were collected on paper rather than a tablet or computer, with a research assistant available to read the survey questions. Patients presenting with needs that could be accomplished remotely were approached by a research assistant to complete the survey starting February 2021 until we reached the pre-determined sample size (N=30) in June 2021. Patients with known dementia, those who normally resident in a long-term care facility, and those presenting with an acute condition (e.g. fall or COPD exacerbation) were ineligible. Because of the small number of respondents, only univariate and bivariate tabulations were performed, in Excel.
RESULTS
83% of respondents said they had devices that could be used for a telemedicine visit and that they went on the internet, but just 23% had had telemedicine visits. Few patients had advanced devices (iPhones, desktops, laptops or tablets); 46% had only a single device that was not IOS based mobile (Table 1). All participants with devices said they used them for “messaging on the internet,” but this was the only function used by 40%. No one used the internet for banking, shopping, and few used internet functions commonly needed for telemedicine (23.3% had email; 30% did video calling) (Table 1). 23.3% of respondents had had a telemedicine appointment. Many reported a loss of connection to their doctor as a concern. Participants who owned a computer or iPhone used their devices for a broader range of tasks, (Table 2 and 3), were aged 65-70 (Table 4), and were more likely to have had a telemedicine visit and to have more favorable views of telemedicine (Table 2). Respondents who had not had a telemedicine appointment endorsed a greater number of telemedicine disadvantages and endorsed less interest in future appointments (Table 2). Respondents who did not own an internet-capable device did not report using any internet functions and none had had a telemedicine appointment (Table 2).
CONCLUSIONS
This small survey revealed significant gaps in telemedicine readiness among seniors who said they had devices that could be used for telemedicine and that they went online themselves. No patients used key internet functions needed for staying safe during COVID, and few used internet applications that required skills needed for telemedicine. Few patients had devices that are optimal for seniors using telemedicine. Patients with more advanced devices used more internet functions and had more telemedicine experience and more favorable attitudes than others. Our results confirm previous studies [7-9] showing generally lower technological proficiency among older adults and some concerns about participating in telemedicine. However, our study is novel in pointing to subtle dimensions of telemedicine readiness that warrant further study—device capacity and use of internet in ways that build skills needed for telemedicine such as email and video calling. Before training seniors to use telemedicine, it’s important to ensure that they have the devices, basic digital skills and connectivity needed for telemedicine. Larger studies are needed to confirm our results and apply multivariate analysis to understand the relationships among age, device quality, internet skills and telemedicine attitudes. Development of validated scales of telemedicine readiness and telemedicine training to complement in-person care can help health systems offer precision-matched interventions to address barriers, facilitate increased adoption, and generally improve patients’ overall access to primary care and engagement with their primary care provider.
Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol
