Victoria L. Chuen, MD1, Saumil Dholakia, MD, MHs2,3, Saurabh Kalra, MD4, Jennifer Watt, MD, PhD1,5, Camilla Wong, MD, MHSc1,5, Joanne M-W. Ho, MD, MSc3,6,71Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto
2Department of Psychiatry, University of Ottawa, Ottawa
4Department of Family Medicine, McMaster University, Kitchener
5St. Michael’s Hospital, Toronto
6Divison of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton
7Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
During the COVID-19 pandemic, physicians provided virtual care to minimize viral transmission. This concurrent triangulation mixed-methods study assesses the use of synchronous telephone and video visits with patients and asynchronous eConsults by geriatric providers, and explores their perspectives on telemedicine use during the pandemic. Participants included physicians practicing in Ontario, Canada who were certified in Geriatric Medicine, or Care of the Elderly, or who were the most responsible physician in a long-term care for at least 10 patients. Participants’ perspectives were solicited using an online survey and themes were generated through a reflexive thematic analysis of survey responses. We assessed the current use of each telemedicine tool and compared the proportion of participants using telemedicine before the pandemic with self-predicted use after the pandemic. We received 29 surveys from eligible respondents (87.9% completion rate), with 75.9% being geriatricians. The telephone was most used (96.6%), followed by video (86.2%) and eConsults (64%). Most participants using telephone and video visits had newly implemented them during the pandemic and intend to continue using these tools post-pandemic. Our thematic analysis revealed that telemedicine plays an important role in the continuity of care during the pandemic, with increased self-reported positive perspectives and openness towards use of virtual care tools, although limited by inadequate physical exams or cognitive testing. Its ongoing use depends on the availability of continued remuneration.
Key words: telemedicine, COVID-19 pandemic, virtual care
Until the COVID-19 pandemic,(1) telemedicine’s uptake in geriatrics was limited by patient unreadiness(2) and provider inexperience.(3) Telemedicine includes telephone visits, video visits, and electronic consults (eConsults). eConsults allow specialists to provide indirect care through asynchronous communication with referring physicians. During the pandemic, temporary billing codes were introduced to support telephone and video visits(4,5) for social distancing. In 2020, the proportion of Ontario patients aged ≥65 years using telemedicine increased from 19.4% to 27.4%.(6)
We aimed to understand current and prospective telemedicine implementation by geriatric providers, and perspectives on its use during the pandemic.
We conducted a concurrent triangulation mixed-methods study using an online survey, between December 22, 2020 and April 30, 2021. We simultaneously collected quantitative and qualitative data for richer and internally validated results. We invited physicians practicing in Ontario, Canada with certification in Geriatric Medicine (Internal Medicine) or Care of the Elderly (COE) (Family Medicine), or who were the most responsible physician to ≥10 long-term care (LTC) residents. We excluded retired physicians, trainees due to their limited clinical autonomy, and geriatric psychiatrists given practice differences and earlier adoption of telemedicine.(7,8) Ethics approval was granted through the Hamilton Integrated Research Ethics Board (December 16, 2020. Project #11154).
We hosted the survey on SurveyMonkey® (Momentive, Waterford, NY), which was piloted by an expert panel of five geriatric specialists. Recruited through listservs, participants received an open weblink containing the consent form and survey. Participation was voluntary, though all participants were offered a $20 gift card.
We collected baseline characteristics, and free-text responses exploring perspectives on telemedicine. Details regarding our survey administration according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)(9) are in Appendix A.
We calculated the participation and completion rates as per CHERRIES.(9) Our primary quantitative outcome was the implementation rate of each telemedicine tool, defined as having used the tool at least once for geriatric care. Secondly, we assessed the proportion of individuals self-reporting a change in perspective on each tool due to the pandemic. Using McNemar’s test, we evaluated differences between the use of each tool pre-pandemic with self-predicted use post-pandemic.
Free-text survey responses were coded collaboratively by two investigators (VC, SD). Codes were refined by reviewing survey responses iteratively using NVIVO software (version 1.4; QSR International (Americas) Inc., Burlington, MA).
We adopted the 6-phase, reflexive-thematic analysis qualitative research methodology combining a predominantly inductive and constructionist orientation.(10,11)
Twenty-nine participants completed the survey (Figure 1), with participation and completion rates of 80% (36/45) and 87.9% (29/33), respectively. Participants were largely geriatricians (22/29, 75.86%) practicing in an academic setting (12/22, 54.5%). Half of the geriatricians were in their first 10 years of practice (Table 1). The telephone was used by most (96.6%), followed by video and eConsults (Figure 2A). Most participants introduced telephone (64.3%) and video visits (72%) during the pandemic.
FIGURE 1 Participants were invited to be approached through email mailing lists catered towards geriatrics; individuals who signed up were then sent an open link to the survey; we excluded geriatric psychiatrists, retired physicians and resident trainees
TABLE 1 Baseline characteristics of study participants
FIGURE 2A Almost all survey respondents had experience providing care by telephone, followed by video and eConsults
We identified four themes relating to telemedicine use in geriatrics during the pandemic.
Telemedicine contributed to patient safety by reducing viral transmission and facilitating continuity of care given restrictions against in-person care.
“Video consults/visits have been essential to providing care and maintaining continuity of care.” (Geriatrician #2)
Video visits were valuable for patients with hearing impairment. The absence of masks enhanced communication via lip reading, and increasing a device’s volume was preferable to masked in-person visits.
“It is easier to communicate and do cognitive testing over video (no masks).” (Geriatrician #10)
Geriatricians emphasized video visits were advantageous over other means of telemedicine as they allowed for some components of the physical exam during the pandemic.
“The video part adds a bit of a physical exam element.” (Geriatrician #13)
Telemedicine was identified as inadequate for complex patients and new consultations, primarily due to limited physical examinations, leading to patient safety concerns.
“Unable to have physical exam, or even allow for gestalt assessment of how sick a patient may be.” (LTC physician #1)
Geriatricians felt telephone visits are limited in their scope to follow-up care, owing to limitations in cognitive and physical assessments. Ultimately, telemedicine cannot fully replace in-person care for comprehensive geriatric assessments.
“Has met a need and has a place in the future but will never completely replace the need for in person medicine.” (Geriatrician #4)
“Telephone visits however, are not helpful for other cases such as falls or movement disorders where a physical exam is necessary.” (Geriatrician #8)
Pre-pandemic, participants identified concerns with telephone visits due to perceived limitations such as inadequate assessments and remuneration. Some identified a role in follow-up care.
“Concern about lack of physical exam and cognitive testing.” (Geriatrician #12)
“Did many follow-up phone calls, but was frustrating that wasn’t reimbursed.” (Geriatrician #18)
During the pandemic, participants, especially geriatricians, felt confident using telephone visits and found them helpful.
“I have a lot of experience and am pretty comfortable with them now. I’m more confident this is a good option in the right circumstance.” (Geriatrician #10)
Participants were divided in their openness towards video visits pre-pandemic. Although open-minded, many identified their limited experience or set-up prevented use. Others worried about patient accessibility or ability to provide comprehensive care.
“Concerned that [video visits] could not facilitate a comprehensive assessment. Also concerned about patients’ access to (and ability to use) technology.” (Geriatrician #12)
Participants recognized its use and benefits during the pandemic and thereafter.
“Now that it has become widespread, there are certain advantages (both to the patient/families and provider) that will make it worthwhile to continue.” (Geriatrician #2)
Pre-pandemic perspectives on eConsults were heterogeneous. Some participants were close-minded due to perceived limitations, yet others found eConsults helpful and efficient.
“Tried to avoid them because they had limitations.” (Geriatrician #17)
“Open and happily used the service.” (Geriatrician #5)
Perspectives identified during the pandemic became more positive and open-minded.
“More open minded towards keeping some [eConsults] in my practice post-COVID”. (Geriatrician #17)
Most identified the pandemic changed their perspective on using telephone (71.4%) and video visits (68%), but only 37.5% for eConsults despite free-text responses reporting increased openness towards eConsults. Compared to pre-pandemic use, telephone (35.7 vs. 82.1%, p<.001) and video visits (28 vs. 84%, p<.01) were predicted to significantly increase post-pandemic, but not eConsults (56.3 vs. 68.8%, p=1.0) (Figure 2B). This aligns with self-reported changes in perspectives.
FIGURE 2B Compared to the reported pre-pandemic use of telemedicine, survey respondents predict significant increased use of telephone and video visits after the pandemic, but not eConsults
Participants expressed continued video and telephone use depended on financial remuneration.(12) Many previously limited using telemedicine due to inadequate payment, despite recognizing its advantages.
“Great to get paid for a service [telephone visits] I already provided for free”, and they would continue using video “if it remains an OHIP-billable service.” (COE physician #3)
“[Continued use of video visits] depends on reimbursement.” (Geriatrician #17)
During the pandemic, geriatric providers widely implemented telemedicine, allowing for continued care and an alternate communication option for patients with sensory impairments. Although reported limitations include incomplete exams, perspectives on telemedicine improved. Ongoing use was anticipated, but depends on adequate remuneration. Our work builds upon telemedicine research in geriatrics during the pandemic(2,3,6,13–16) and informs key stakeholders in developing models of care and allocating funds to telemedicine.
Similar to previous studies,(3) our participants felt unequipped or hesitant to use telemedicine due to perceived limitations of the physical examinations or inadequate remuneration.(3,15,17–20) Due to the variability in a patient’s ability to use telemedicine(3,21) and its limitations in assessment, geriatric providers must individualize its use.
Respondents predict sustained use of telephone and video visits, suggesting perceived benefits extend beyond the pandemic. Our results support the known advantages of telemedicine including improved access to care, costs, and patient satisfaction.(19,22–24) However, continued use depends on adequate remuneration. After our survey closed, the Ontario Medical Association ratified a new Physician Service Agreement with the Ontario Ministry of Health.(25) This agreement aims to ensure telemedicine is used only when clinically appropriate and necessary. However, it introduces additional restrictions for telephone visits, which are now remunerated at 85% of an in-person visit fee, and therefore limits virtual care to rural communities lacking reliable internet for videoconferencing. Telephone is preferable over video for older patients who find videoconferencing inaccessible or lack caregiver assistance.(2,3) Inadequate reimbursement previously discouraged telemedicine use, despite identified benefits,(19) a sentiment our participants shared. Our results demonstrate a perceived role and increased acceptance for telephone and video visits by geriatric providers, which funding authorities should consider. The issue of reimbursement was absent for eConsults, likely due to the lack of recent fee code changes.
We acknowledge limitations to our study. Our sample size was small with a majority of participants being geriatricians; therefore, the generalizability to COE and LTC physicians is limited. Results are also subject to participation bias from individuals with strong opinions about telemedicine.
Telemedicine use in geriatrics increased during the pandemic allowing for continuity of care and is likely to continue with sustainable funding. With the changing landscape of the pandemic and funding in Ontario, further research is required to determine the ongoing use and sustainability of telemedicine in geriatrics, and to identify strategies to improve upon the accuracy of virtual assessments.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare the following interests: VC received the “Dr. Christopher Patterson Resident Research Grant in Senior’s Care Award”; however, funds were used only for the sole purpose of this research project. JH participated as a volunteer member of the Ontario eConsult Centre for Excellence Clinical Advisory Group between 2019 and 2020 and is the Co-Executive Director of GeriMedRisk. All other authors have no financial or personal conflicts of interest to declare.
This work was supported by the “Dr. Christopher Patterson Resident Research Grant in Senior’s Care Award” through the Division of Geriatrics, Department of Medicine at McMaster University. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
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*The data in this manuscript has been presented in an oral presentation at the 2022 Canadian Geriatrics Society Annual Scientific Meeting. ( Return to Text )
Canadian Geriatrics Journal, Vol. 26, No. 2, June 2023