Sofia Nene, MD1, Magnus Rauch, BSc2, David Belanger, MD3, Roxanne Bennett, MSc2, Gregory Berry, MD1,2,4, Nathalie Saad, MD, MBA5, Michelle Wall, MSc2, José A. Morais, MD2,6, Suzanne N. Morin, MD, MSc1,2,31Faculty of Medicine and Health Sciences, McGill University, Montreal
2Research Institute of the McGill University Health Centre, Montreal
3Division of General Internal Medicine, McGill University, Montreal
4Department of Orthopedic Surgery, McGill University, Montreal
5Division of Respiratory Medicine, McGill University, Montreal
6Division of Geriatrics, McGill University, Montreal, QC
In the context of the ongoing COVID-19 pandemic, rapid transitions have been made towards telehealth. Optimal use of telehealth in elderly patients remains poorly understood and adaptation challenges persist. Our study aimed at identifying perceptions, barriers, and possible facilitators to telehealth use amongst elderly patients with comorbidities, their caregivers, and health-care providers (HCPs).
Health-care providers, patients 65 years and older with multiple comorbidities, and caregivers were recruited from outpatient clinics and invited to complete an electronic self-administered or telephone-administered survey on their perceptions of telehealth and of barriers to its implementation.
A total of 39 health-care providers, 40 patients, and 22 caregivers responded to the survey. Most patients (90%), caregivers (82%), and HCPs (97%) had experienced telephone visits, but few were conducted via videoconference platforms. Patients and caregivers showed interest in pursuing some future telehealth visits (68%, 86%, respectively), but felt they lacked access to technology and skills (n=8, 20%), and some felt that telehealth visits may be inferior to in-person visits (n=9, 23%). HCPs showed interest in incorporating telehealth visits into practice (n=32, 82%), but identified challenges in lack of administrative support (n=37), lack of HCP (n=28) and patient (n=37) technological skills, and limited infrastructure (n=37)/internet access (n=33).
Older patients, caregivers, and HCPs show interest in pursuing future telehealth visits but elucidate similar barriers. Facilitating access to technology, as well as to administrative and technology support guides, could promote high quality and equal access to virtual care for the older adult.
Key words: telehealth, barriers, patient engagement, survey
In the wake of the COVID-19 pandemic, a series of unprecedented measures to mitigate the spread of the virus were implemented including large-scale social isolation, restriction of public gatherings, and nationwide lockdowns. Although these social distancing strategies have been necessary from a public health standpoint, they have introduced challenges in the management of many chronic medical conditions, and have resulted in social isolation and limitation in social activities.(1) For elderly patients with multiple comorbidities, this may result in fragmentation of care, in deterioration in their clinical status, and substantial anxiety.(2) In an attempt to reduce transmission of COVID-19 and close the divide in health-care accessibility, rapid transitions have been made towards telehealth throughout the medical field. According to a study by Canada Health Infoway data published in June 2021, rates of virtual care rose from about 10% in 2018 to approximately 60% of health-care visits across Canada.(3) This has been the case across many medical specialties, notably in primary care. Specifically, Ontario saw a rise in primary care virtual visits from 1.2% in July 2019 to 71.1% in July 2020.(4)
Telehealth can be defined as the convergence of digital technologies with health to enhance its promotion, to improve disease management, and to provide remote health-care delivery.(5,6) It focuses on connecting patients, their caregivers, and their treating team, in synchronous (e.g., home telehealth visit) or asynchronous manners (e.g., home monitoring), with the goal of enriching patient-centred care.(7,8) Effective use of these technologies has been shown to decrease the number of hospital visits and the costs of treatment, and improve patient experience.(9–11) There is growing evidence that, with proper policies in place, health care could be safely and confidentially delivered through telehealth visits.(12)
Adoption of telehealth has not been without its challenges for both patients and their health-care providers (HCPs). It has been noted that this transition may disproportionately affect older patients, whose health condition, socioeconomic status, and digital literacy could cause additional challenges.(13) The level of eHealth literacy and adoption of technology among older Canadians has increased; nevertheless, to a lesser degree in those who are 65+ years and in those with lower levels of education.(14) This suggests that older populations would benefit from personalized solutions that integrate their caregiver and treating team, and provide adequate technological support to help mitigate health-care access inequities.(15) Although there is an increasing body of literature on telehealth use, evidence has been predominantly in patients with single-organ disease, and those with cognitive impairment are often excluded from studies.(16)
For new technologies to succeed, they must accommodate a spectrum of user needs. Patients need skills and tools to proactively apply technology information. In addition, use of new technology should be personally meaningful in terms of relevant self-care, and must serve to bring health into focus at a personal level and not define patients based on their disease state.(17) Therefore, novel and hybrid models of outpatient care that combine in-person clinic visits interspaced with personalized telehealth visits with ongoing remote educational and monitoring support are needed. Data related to access to electronic devices, proficiency, and interest in using digital health, as well as constituents of effective remote care visits, continue to be lacking for older and frail adults.
Therefore, the aim of this study was to evaluate the perceptions, the barriers, and facilitators to telehealth in adults of 65 years and older with multiple comorbidities, as well as in their caregivers and their health-care teams.
We conducted a survey of patients, caregivers, and health-care providers during a period of three months, from February to May 2021.
Men and women over the age of 65 with at least three comorbidities followed in the General Internal Medicine or Geriatrics clinics of a large university tertiary care hospital were approached to participate in the study. Exclusion criteria included living in a long-term care institution, inability to provide informed consent and inability to communicate in French or English, and refusal to take part in the survey. Potential participants were approached by an HCP and were then referred to trained research personnel, who screened them for eligibility.
Caregivers of patient participants or of patients who were not eligible to, or refused to, participate in the study were also approached. Exclusion criteria and recruitment procedure of this group were similar to that of patient participants.
Health-care providers included physicians, nurses, and other HCPs working in the internal medicine, geriatric medicine or orthopedics outpatient clinics at the same institution. HCP recruitment was done through targeted email by the clinic leadership.
Surveys were developed by our research team in collaboration with patient partners, caregivers, physicians, and nurses. Questions were designed to obtain input from each group regarding their experiences and perceptions of telehealth in an engaging manner using specific web-based survey design and technical interface.(17) We categorized telehealth visits as visits that occurred using the telephone (telephone visits) or visits that occurred using a videoconference platform (videoconference visits).
The surveys were conducted using the REDCap Platform (Vanderbilt University, Nashville, TN) an online survey development cloud-based software that is compliant with Canadian privacy and accessibility standards (W3C) and does not collect computer internet protocol (IP) address or any other participant identifying information.(18) Surveys were available in either English or French. Consent was assumed based on the completion of the survey. The study was approved by the McGill University Health Centre Research Ethics Board.
Eligible participants were invited to complete a survey composed of 25 close-ended questions and one open-ended question (Appendix A). Eight questions were related to demographics (including age, race, level of education, and current living arrangement), and known medical conditions. Next, participants were questioned on their access to technology and previous experience with telephone or videoconference visits. Participants were asked to rank their perceptions of telehealth visits, as well as benefits and challenges related to their implementation in the future, according to a Likert-type scale (Strongly disagree, Disagree, Neutral, Agree, Strongly agree). Finally, in an open-ended question, respondents were asked to list barriers contributing to future use of telehealth visits. This survey was either self-administered online or over the phone by our research personnel. Caregivers were allowed to complete the survey on behalf of patients, with real-time patient input, language-barrier, for technical or accessibility reasons. No personal ID information was gathered, and the data were entered directly into the REDCap platform.
Eligible caregivers were invited to complete a similar survey composed of 16 close-ended questions and one open-ended question pertaining to experience, and perception of benefits and challenges related to assisting in conducting telehealth visits (Appendix B). In the open-ended question, caregivers were also asked to list barriers to pursuing this modality.
A self-administered online survey was developed and distributed to all HCPs affiliated with the clinics in question. Participants were notified by email of the survey’s imminent release. The survey was sent by their divisional director in February 2021; a reminder was sent two weeks after its initial distribution. This survey consisted of 15 close-ended questions and one open-ended question (Appendix C). Three questions pertained to demographics of the HCPs; nine questions were related to previous experience with various telehealth modalities, as well as any technical issues experienced during telehealth visits. Next, HCPs were asked to express their personal comfort level using and troubleshooting various telehealth modalities and expressed their answer on a five-point Likert scale (Strongly disagree, Disagree, Neutral, Agree, Strongly agree). Similarly, respondents were asked to rate their perception of various barriers as Not important, Mildly important, Moderately important, Important, Very important. Finally, HCPs were asked to list suggestions they would have to improve sustainable telehealth implementation in the future.
The close-ended questions were analyzed using descriptive statistics expressed as frequencies and percentages for categorical variables and as means and standard deviations (SD) for continuous variables. Thematic content analysis was conducted for the open-ended questions and principles of simple induction without research-based expectations were applied.(19) Content analysis was performed by a first analyst (MR) and validated by a second analyst (SN) for patient and caregiver responses. For the HCP survey, open-ended responses were coded by a first researcher (DB) and then further validated by a second (SN). Content was organized into categories through a consensus process considering the possible range and variability of subcategories. Participants responded to open-ended questions in either French or English. Therefore, both French and English data were analyzed and validated simultaneously by bilingual analysts (SN, DB, MR).
Amongst the fifty-three patients who met inclusion criteria approached for the study, forty patients completed the survey questionnaire (75% participation rate) (Appendix D). The mean age of participants was 79.5 (SD 7.1) yrs, most were women (N= 27; 68%) and self-reported white race/ethnicity (N= 37; 93%). The majority reported living at home alone (N= 14; 35%) or with their spouse (N= 18, 45%). Eleven (28%) respondents reported having help at home from private or community services (Table 1). Most (71%) of respondents had a college degree or higher. The most common identified medical conditions amongst participants were arthritis (25%); visual impairment such as cataracts, glaucoma, macular degeneration (24%); cardiovascular diseases (23%); and diabetes (10%). Almost all previously had experienced telephone visits and only two had previous experience with videoconference visits.
Out of a total of twenty-four caregivers who were approached for the survey, twenty-two agreed to participate and responded to the survey (92% participation rate). The majority were women (N= 17, 77%) with a mean age of 68.7 (SD 13.0) yrs (Table 1). Most respondents were spouses (N=10, 46%) or children (N=10, 46%) of a patient participant. Caregivers reported having access to a variety of technological modalities for telehealth visits (Figure 1). Amongst this group, 18 caregivers (82%) reported having previously participated in telephone visits with only very few experiencing technical difficulties (N=2, 11%) (Table 2). Amongst the caregivers who previously participated in telehealth visits, 12 (67%) were in-person with the patient, one participant (6%) had connected via a three-way call, and two (11%) were on a separate call with the patient. Two people responded to have experienced videoconference visits, in-person with the patient, without any technical difficulties. Caregivers mostly felt comfortable assisting with the basic set-up and troubleshooting of a telehealth visit (Figure 2).
TABLE 1 Participant Characteristics
FIGURE 1 Participant access to technology
TABLE 2 Technical problems encountered during telephone and videoconference visits
FIGURE 2 Caregiver comfort level assisting patients in caregivers/family members
We identified seventy HCPs who met inclusion criteria to take part in the online survey. A total of thirty-nine surveys were completed (56% response rate) (Appendix D); participants had an average age of 51.4 (SD 13.7) yrs and gender was equally distributed in this group (Table 1). Amongst the HCPs, the majority were General Internal Medicine physicians. Ninety-seven percent (n=38) of participants reported having previously conducted telephone visits; however, only 41% (n=16) had conducted videoconference visits, and most reported experiencing technical difficulties both during telephone and videoconference visits (Table 2).
All groups surveyed reported having access to a telephone either with or without hands-free capability (Figure 1). While 70% and 90% of patients and caregivers, respectively, reported having access to a device (e.g., mobile device, computer, or tablet) capable of performing a videoconference visit, only about 45% of HCPs reported having access to a computer with videoconferencing capabilities in the clinic rooms.
The most used platform for videoconference visits amongst all groups was Zoom or Zoom Telehealth, with 17 HCPs, two patients and one caregiver. Participants reported no technical issues during their videoconference encounters, whereas HCPs noted difficulty with the connection, inability to hear or see the patient, and patients who did not understand how to use the videoconference platform (Table 2).
In general, health-care providers felt that future visits could be continued either by telephone or videoconference modalities (19 HCPs for telephone, 19 videoconference). Amongst patients, 14 (47%) noted they had no preference regarding which mode of telehealth visits they would prefer in the future, whereas 11 (37%) patients preferred telephone visits and five (17%) preferred videoconferences. Eighty-two percent of HCPs reported wanting to continue to offer telehealth visits after the pandemic was over. Most patients had positive perceptions of telehealth visits in general and were able to identify benefits to pursing this in the future (Appendix E). Thirty patients (75%) reported that they were interested in pursuing telehealth visits in the future, of which 28 (68%) patients noted wanting to pursue future telehealth follow-ups at least half the time. Most caregivers (19, 86%) noted that an ideal frequency for telehealth would be every visit. Specific to videoconference visits, HCPs reported that they were likely to incorporate this type of consultation in their practice (n=32); nevertheless, HCPs still responded that they lacked adequate knowledge (n=13) and preparedness (n=14) to conduct a videoconference consultation.
Patients, caregivers, and HCPs identified barriers to participating in telehealth visits in the open-ended questions (Appendix F, Appendix G). Patients and caregivers noted health-related barriers including cognitive impairment (n=6), caregiver health limitations (n=2) and sensory impairment including vision and hearing (n=2). Some patients (n=9) and caregivers (n=4) perceived telehealth visits as inferior to in-person visits.
Overall, most barriers identified by patients and caregivers and HCPs pertained to technology use difficulties and lack of access to tools and guides. Some of the themes that were identified included patients or caregivers not feeling comfortable with technology (n=8). Lack of skills by patient or caregiver was also identified as an important barrier by HCPs (n= 37) (Appendix G). Similarly, HCPs also felt that they lacked the technological skills to facilitate telehealth visits without support (n=28).
In terms of technology infrastructure, patients, caregivers, and HCPs all identified poor internet connection (n=1 patient, 1 caregiver, 33 HCPs) as a barrier to providing videoconference visits, and one patient reported elevated costs of technology as a barrier. HCPs’ responses also highlighted challenges related to lack of technology availability (n=37), lack of administrative support (n=28), and significant workload related to the process of implementing this technology (n=32).
HCPs’ suggestions to reduce the aforementioned barriers pertained to improved access to technology (n=17) including infrastructure and technological support, as well as administrative support for scheduling and set up (n=29). Further suggestions included creation of tools and guidelines to facilitate a safe and confidential process of conducting telehealth visits both for HCPs, and patients and their caregivers (n=16) (Appendix H).
We found that while most patients, caregivers, and HCPs respondents have previously experienced telehealth visits, few of these visits were conducted using videoconference platforms. In general, participants and caregivers have access to devices able to conduct videoconference visits; however, hospital infrastructure and access to technology were reported to be lacking by the HCP group. Moreover, HCPs noted they would like to integrate videoconference consultations into their practice, but felt they lacked administrative support and guidelines on troubleshooting options both for themselves and the patient. Manipulation of technology and health-related barriers were the other most frequently identified barriers. Participants reported wanting to pursue some degree of virtual visits in the future. Participants noted that telehealth visits could facilitate communication with the HCPs, especially if the patient and/or caregiver have cognitive or mobility issues.
Our study revealed that few of the telehealth visits that patients, caregivers, and HCPs already experienced were conducted using videoconference platforms. This is in keeping with previously reported findings amongst patients of all ages and is explained by the relative ease of use and technological availability of phone visits compared to that required for videoconferences, as we have also identified in our study.(20)
In a 2018 study commissioned by the Canadian Medical Association on public opinion of digital health technologies (additionally mentioned in the Organization for Economic Cooperation and Development [OECD] 2020 report),(21) it was reported that seven out of ten participants surveyed said they would take advantage of virtual visits in the future.(12) This is consistent with our findings which revealed interest to participate in telehealth visits in the future amongst patients, caregivers, and HCPs. It is noted, both in our study and in currently available literature, that patients prefer a hybrid formula for future health-care delivery.(22) This will require the creation of novel models of outpatient care that combine in-person/in-clinic visits interspaced with personalized telehealth visits with ongoing remote educational and monitoring support.
Most caregiver respondents in our study preferred to pursue telehealth in every visit. This preference may be explained by the facilitated accessibility to health-care providers and the elimination of distance or time constraints associated with travelling. This reiterates the importance of ensuring that the caregiver is included in every visit, even if they are only present remotely.
Barriers identified in our study were similar across HCPs, patients, and caregivers, as well as to those previously reported in literature.(23–26) Amongst the three groups, lack of administrative support, technological skills, and local infrastructure were frequently identified.
While some physicians feel sufficiently prepared to conduct videoconference consultations, frequent comments were made pertaining to the need for more standardized tools and guidelines for patients and staff, as well as dedicated administrative and technological support to ease the application of telehealth. These are factors that should be considered in the future development of interventions and policies aimed at supporting telehealth for health-care delivery in the elderly. As per findings in a study by Kalicki et al., physicians are not always aware of non-medical barriers that may be limiting proper telehealth use, notably the financial situation of the patient including their ability to obtain a videoconference device and pay for the internet connection.(27) This was not a barrier that we identified. However, it remains a factor that should be taken into consideration, especially in the elderly population. A proposed solution for this is a collection of targeted data on the patient’s medical and non-medical capacity to engage in a telehealth visit prior to pursuing this modality.
Study respondents felt that telehealth visits will facilitate health-care accessibility and communication with the HCPs, especially if the patient and/or caregiver have cognitive or mobility issues in the future. It is known that improved accessibility to health care in the elderly limits fragmentation of care, improves survival outcomes, and alleviates substantial anxiety.(28) Bashshur et al. showed improved outcomes with telehealth: decreased hospital admissions, emergency room visits and even mortality in patients with chronic diseases (i.e., COPD, heart failure and stroke).(9) Currently, there is little data pertaining to these outcomes in the elderly population.
Some patient participants in our study perceive telehealth visits as inferior to in-person visits. Although reasons for this were not explored in this study, possible causes including perceived lower quality care due to limited physical exam, loss of interpersonal connection, and technology and health-literacy disparities in older and more vulnerable populations have previously been identified.(29,30) Interestingly, in a study by Ladin et al., this dissatisfaction was mainly noted by HCPs and was not consistently shared by patients.(30)
A strength of our study is that we identified the perceptions and challenges to telehealth not only from the perspective of elderly patients, but also from their caregivers and their HCP team. Perspectives and difficulties in implementation of telehealth in the older population with multiple comorbidities, including cognitive impairment, is poorly represented in current literature,(31) and obtaining information from all stakeholders is a crucial step to finding solutions.
Our results are limited by the survey methodology and the relatively modest number of participants in all groups. Our sample size was small because recruitment occurred early in the COVID-19 pandemic. It was therefore increasingly challenging to reach out to potential participants. Furthermore, our results only apply to the population seen in tertiary academic settings, thereby limiting their generalizability. However, the demographic information in all groups is representative of the study populations. There were significantly more physician responders than other HCPs, which is in keeping with the professionals who participated the most in telehealth visits. Amongst the patient and caregiver groups, patients were preselected by their HCP. This accounts for the higher participation rate and an overall lower number of participants, and supports the presence of a selection bias, since patients and caregiver participants were already positively disposed to telehealth measures. Nonetheless, our findings are in keeping with previously published data regarding demand and interest.(22) Participation bias was reduced by providing multiple pathways to completion of the survey (for example, patients or caregivers with lower eHealth literacy or of lower socioeconomic background who wished to complete the survey with the help of a research staff on the phone). The surveys were only available in French and English, thereby excluding participants who could not communicate in these languages. This is a well-recognized challenge in digital technologies, and the availability of tools solely in English(32) leads to inequities in health-care delivery.
The ongoing COVID-19 pandemic is forcing us to redesign the way we deliver care, now and for the future. Telehealth offers a promise for the provision of health-care delivery in the elderly. There is evidence of increased demand to incorporate telehealth for health-care delivery in the elderly; however, important challenges in implementation of this technological avenue are still present. In order to bridge this digital divide, we must continue to adapt telehealth to create a more personalized approach to meet the unique needs of older adults, specifically those with multiple comorbidities. Nonetheless, telehealth should not be “one-size-fits-all” model, but rather tailored to the patient’s needs, their interest, and the available technological resources.(27) Our study findings highlight an opportunity for broader engagement by hospitals, various stakeholders, and policymakers to provide necessary technological and infrastructure support, and for the creation of guidelines to facilitate the transition to telehealth for the older adult.(12,33)
The authors would like to thank the respondents for their participation in the surveys. SNM is a scholar of the Fonds de Recherche du Québec en Santé.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare there are no conflicts of interest.
This study was funded by the Montreal General Hospital Foundation Helen McCall Hutchinson Scholarship. The funding source had no role in the design of the study, analysis of the results, writing of the manuscript or decision to submit for publication.
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Canadian Geriatrics Journal, Vol. 26, No. 1, March 2023