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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;00 - 00;00;40;09
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. Stay at home orders and concerns about contracting COVID-19 led to the rapid closure of many health facilities in the early stages of the pandemic. Telemedicine quickly became the dominant mechanism for obtaining care for everything other than emergencies and medical procedures. Now, adoption of telemedicine was rapid among providers, many of whom were unaccustomed to this form of care, and patients adapted quickly and by most accounts were quite satisfied with this new modality.
00;00;40;29 - 00;01;12;22
Alan Weil
Telemedicine also helped overcome some longstanding access barriers, such as long travel times in both urban and rural settings. But is telemedicine here to stay, or will it fade away as doctors and patients reacclimate to in-person visits? That's the topic of today's episode of “A Health Podyssey”. I'm here with Gillian SteelFisher, a principal research scientist at the Harvard T.H. Chan School of Public Health and director of Global Polling in the Harvard Opinion Research Program.
00;01;13;07 - 00;01;36;24
Alan Weil
Dr. SteelFisher and coauthors published a paper in the April 2023 issue of Health Affairs, assessing the attitudes of primary care physicians and patients toward telemedicine during the COVID-19 pandemic. They found that while most patients and physicians were satisfied with their experiences, many physicians had concerns about the visits and two-thirds of patients hoped to return to in-person visits.
00;01;37;08 - 00;01;43;16
Alan Weil
We'll discuss these findings and more in today's episode. Dr. SteelFisher, welcome to the program.
00;01;43;27 - 00;01;46;05
Gillian SteelFisher
Thank you so much for having me. It's great to be with you.
00;01;47;05 - 00;02;07;04
Alan Weil
This is a really interesting paper and an important topic. And before we get into the findings, maybe you could set the stage for our listeners. Why is it worth asking the question, what did patients and physicians think about their experiences with telemedicine and whether they want to continue seeing each other in that way?
00;02;07;24 - 00;02;26;23
Gillian SteelFisher
That is a great question. And the one that's been on my mind. You know, I think as we were just discussing in your introduction or just listening to that, you know, telemedicine was intensely enabled during COVID and in an effort, of course, to make sure that people could access medical care without risking transmission. And so there were so many policies put into place, right?
00;02;26;23 - 00;02;47;28
Gillian SteelFisher
There were things that people want to sort of undo the factors that they thought were constraining telemedicine growth for a long time. We had policies that facilitated reimbursement, policies that allowed providers to use popular and familiar platforms, policies that allowed providers to access or to provide care across state lines. And these were all the things that people thought was like holding telemedicine back.
00;02;48;16 - 00;03;16;08
Gillian SteelFisher
Right? And so telemedicine boomed as predicted. And then the policies did not change or telemedicine declined. You know, just a few months after the peak of COVID, the number of telemedicine visits was down by over half. I mean, this was just a precipitous drop. And so if we think that telemedicine for primary care is this sort of piece of the puzzle as a critical tool in the future of medical care, we've been talking about that for a long time.
00;03;17;03 - 00;03;34;10
Gillian SteelFisher
But the things that we thought were holding it back are not exactly the factors that are keeping, in fact, this opens up some questions. So what is it? What is really going on? And we want to understand the telemedicine experience from both halves of the equation, from the physician side and the patient side.
00;03;35;16 - 00;04;03;07
Alan Weil
So I really appreciate that introduction. And I know as we go further in our conversation, we are going to talk about the policy environment. There is a lot of attention being placed on retaining some of the rules that enabled the growth of telemedicine and what you're saying is that's a factor, but it's only one. So let's talk about the factor that you focused on in your paper and that you just alluded to, which is whether it's allowed or not, people have to want to use it.
00;04;03;25 - 00;04;13;16
Alan Weil
In your paper, you asked primary care physicians and patients about their experiences with telemedicine. What did they think? Were they generally satisfied?
00;04;13;29 - 00;04;38;20
Gillian SteelFisher
Yeah, I mean, I think that's the first step in the exploration, right? Just to understand, like, well, did it stop because people just hated it, right? I mean, did they think it went terribly? And, you know, I think in simple terms, the short answer is no. Actually, people didn't hate it. Nearly all physicians, 90%, said that their video visits during the pandemic went well and patient views were pretty well aligned with that.
00;04;38;20 - 00;05;00;02
Gillian SteelFisher
About 92% said their last visit went well. And what's even more important, I think, is that majorities of both of these groups felt that telemedicine visits were an important resource for accessing health care during the pandemic. I mean, they got the value. You know, physicians said this is really important to reach my patients, and patients said, without this I might have delayed care or even not seen a doctor at all.
00;05;00;18 - 00;05;08;17
Gillian SteelFisher
So they're kind of getting it in the context of COVID. But there's clearly something more that's going on as the experience went on for longer.
00;05;09;17 - 00;05;27;28
Alan Weil
Well, you know, and that's consistent with my own experience. And it also is sort of consistent with what I think about at the workplace, which is, you know, we couldn't go to the office, so we had to use all these new platforms. And, you know, we figured out how to get the work done. And we were generally satisfied, if you will, once we got over the hurdles.
00;05;27;28 - 00;05;52;02
Alan Weil
But then the question is, is it as good as, and that's for a long time been a question about telemedicine, is it as good as an in-person visit? I wonder if you could tell us a little bit about what each group, both the physicians and the patients, said about the quality of the visit and particularly the dimensions of quality that were important to them in deciding whether or not telemedicine was as good as an in-person.
00;05;52;17 - 00;06;12;22
Gillian SteelFisher
Yeah, I mean, I think that's right where our minds went. We thought, well, okay, satisfaction, people have talked about that a lot. But what about the underpinnings of this? Right? What about the quality of the care? And their results were definitely more mixed. In fact, physicians, no, everybody said it went well, but they actually had a somewhat negative perception of the quality of video visits.
00;06;13;04 - 00;06;42;17
Gillian SteelFisher
You know, more than half said that the quality by video, even if the pandemic wasn't, what it could be, seeing a patient in-person in the pandemic, and they had particularly lower assessments for types of care that I guess I would call them sort of bread and butter of primary care. I'm not a primary care physician, but to the layperson, they feel like the primary care, you know, the bread and butter, you know, two thirds said it was worse, the quality was worse for routine or preventive care, for managing chronic conditions, like things that you want it to be good for.
00;06;43;14 - 00;07;06;22
Gillian SteelFisher
But, you know, we didn't get high ratings from physicians on the quality side. There were some spots where folks were more receptive in terms of quality. You know, PCPs (primary care physicians) thought that video visits provided this thing where better quality for mental health provision, for triaging folks who might have COVID, you know, those with COVID symptoms. But, you know, overall, they were not, they didn't have great ratings on the quality in terms of what it could be,
00;07;06;22 - 00;07;25;24
Gillian SteelFisher
you know, even in a pandemic context. Patients are more positive than physicians are, but still, even among patients, about a third said that the quality in their video visit was worse than what it could be in person. And, you know, I think that's meaningful and it's worth exploring, you know, well, why? And, what were the features of it?
00;07;25;24 - 00;07;27;14
Gillian SteelFisher
And so we kind of dug in there as well.
00;07;28;22 - 00;07;31;27
Alan Weil
You know, say a little bit more about that side of the equation.
00;07;32;00 - 00;07;51;25
Gillian SteelFisher
Yeah. I mean, I think when, well, we asked directly. We said to people, okay, you just told us that the quality wasn't as good. Why? Just straight up asking. It was interesting. The biggest reason that both groups felt the care was lower quality was the lack of a physical exam. And this was 90% in both groups. And the other concerns were sort of similar.
00;07;52;07 - 00;08;14;29
Gillian SteelFisher
Like physicians wanted to be able to get information on vital signs and patients were nervous about providing that kind of information accurately. You know, they were sort of talking about the same general thing, which is that there needs to be this like hands on dimension of care in order for it to be high quality. And, you know, I think the evidence around the clinical importance of physical exams is not quite as clear as all that.
00;08;15;10 - 00;08;31;26
Gillian SteelFisher
But this is the critical perception, like what you were saying earlier, you know, in order to use it, people have to believe in it. And so people are feeling like they're giving and getting less quality care because they can't get that information. And I think the future of telemedicine is going to have to grapple with that for sure.
00;08;33;05 - 00;08;56;18
Gillian SteelFisher
We also, you know, explored other things like, you know, did they feel it was like about the rapport? Was rapport the same? Because in theory, right, the screen puts distance between us and we don't want to feel that. But, you know, it was interesting. Like, again, physicians were a little more negative than patients. And almost half said that the rapport was worse, but only 20% of patients did.
00;08;57;10 - 00;09;18;03
Gillian SteelFisher
You know, and maybe patients were sort of just seeing that they were doing online for so many things. Right? Health care was one in many series of things that we're trying to accomplish during the pandemic, where they had to go online. They had to, you know, view the world through the Zoom window. We also thought maybe it was like about getting squeezed for time.
00;09;19;05 - 00;09;38;16
Gillian SteelFisher
And actually we didn't see much sort of negative review from either physicians or patients on that front. So it wasn't about these other features. You know, and of course, we asked about like the technology side, right? So how was the video and audio quality and was that interfering? Because it would make sense that it was, right? And it's true,
00;09;38;16 - 00;10;04;29
Gillian SteelFisher
there was some technological issues that came up with the visits. Again, more so for physicians, in part because they’ve got so many visits. Right? It's in part the way physicians assess it. It's their clinical expertise and it's their work. Right? It's important to them in this specific way. They have so much more experience with it that, you know, I think their ratings overall are more negative than patients for whom this wasn't like the whole of their lives during the pandemic.
00;10;04;29 - 00;10;35;26
Gillian SteelFisher
Right? This was one feature of a lot of things. But, you know, there were frequent technological issues that came up in the visits, again, for physicians. And, you know, there were connectivity problems and software and, you know, they had to hang up and there were problems. So all of those things kind of existed. And I think those you know, you think, well, those are all important features of the experience that we want to understand them and possibly address them if we want to make telemedicine more useful for folks.
00;10;35;26 - 00;11;09;26
Alan Weil
So one of the things I'm struck by as you provide this answer is that if you look at the evolution of quality metrics in health care in general, there are lots of technical measures. Are people getting the preventive care they need? Is their blood glucose controlled? But there are all of these other elements of what one may think of as sort of the soft skill side, which is how people feel about their interactions with the health care system, whether they're listened to, whether they get clear instruction, whether they feel a rapport with their clinician.
00;11;10;05 - 00;11;41;12
Alan Weil
And in essence, your survey results mirror the complexity of the quality enterprise in health care, which is that physicians particularly are trained primarily on these, you know, disease treatment and management and diagnosis skills that are a form of technical quality. But when you ask the patients, they say they're interested in a whole host of factors that aren't just about the technical quality of the interaction.
00;11;41;12 - 00;12;10;10
Alan Weil
And that complexity comes through in your survey results, that there is not one measure of quality. There are many different measures of quality. And from a physician side, they’re maybe concerned about whether they have the information they need because they can't put their hands on the patient to improve the diagnosis. But factors like making a connection and being listened to, those, you can have different perceptions whether you're in-person or electronic.
00;12;10;24 - 00;12;18;28
Alan Weil
Those vary across settings. And clinicians and patients in ways that aren't just tied to the technology. I feel, seems to me that that comes through.
00;12;19;13 - 00;12;37;08
Gillian SteelFisher
Yeah, I completely agree. I mean, we were really trying to use this survey as a way to expand the kind of considerations that you're talking about because there's so many stories out there that sort of stop at satisfaction. Right? And really what we're trying to say is there's more to that, right? Customers that are satisfied, they're going to, they might just say like, yeah, it's enough.
00;12;37;08 - 00;13;02;18
Gillian SteelFisher
Like it's okay. But if we really want to use this as a, we want to develop this as a tool for enhancing people's care, enhancing their quality of life, enhancing their health, right? We're going to have to go beyond that. And I think we took inspiration from the folks who are really looking at this in this multidimensional way and try to put that into the online context and try to assess all of these different features and what that would look like in the context of a Zoom meeting.
00;13;03;03 - 00;13;18;19
Gillian SteelFisher
Right? How do we think about those in that context? And so I think it's exactly as you say, there's a nuance in the fabric of that experience that we need to be paying attention to as we're thinking about moving telemedicine into a future where it's a meaningful part of care.
00;13;19;11 - 00;14;05;07
Alan Weil
Well, I want to talk to you more about what we do with this sense of satisfaction, but maybe not excellence in terms of setting the right policy context for telemedicine into the future. We'll have a chance to discuss those topics after we take a short break. And we're back. I'm speaking with Dr. Gillian SteelFisher about physicians and patients attitudes and experiences with telemedicine during the COVID-19 pandemic.
00;14;05;17 - 00;14;27;07
Alan Weil
Before the break, we spent a lot of time talking about satisfaction, and maybe that is sort of exactly the right word. You're satisfied, but that doesn't mean you're bowled over. What's striking to me in the findings is that you move from really very high levels of satisfaction to another question, which is do you want to continue using telemedicine into the future?
00;14;27;21 - 00;14;41;07
Alan Weil
And the answers there are quite different. What can you tell us about what people said about their preferences for using telemedicine into the future, and particularly, again, how those differ by physician and patient characteristics?
00;14;42;04 - 00;15;05;10
Gillian SteelFisher
So this I think, is the central contrast, as you point out, right? Like, oh yeah, this, this is okay. Like telemedicine video visits, they’re okay. They did their job. We appreciate them, but I don't want to do that for the rest of my life. I don't want to go, I don't want to stay there. Right? And what's interesting is that most physicians and most patients wanted to transition back to all, or almost all, in-person visits.
00;15;06;05 - 00;15;27;17
Gillian SteelFisher
And it's not just the survey, right? Our survey is completely consistent, what we're seeing in the clinical context, that people are in fact going back to in-person visits. So they were telling us the truth in the survey. They're like, yeah, good enough, but this isn't what I want. And we need to sort of, you know, see that and respect it and say like, okay, well, what's going on here?
00;15;27;17 - 00;15;46;00
Gillian SteelFisher
And I think we got some insights from asking people about the features of the experience, but we also want to see how those features then predicted their willingness to go back. What's the relationship? And to be honest, right, you know, and it may be the bias of being in health policy research, but, you know, I thought it'd be all about quality, right?
00;15;46;02 - 00;16;09;04
Gillian SteelFisher
It'd be like physicians are like, oh, if it wasn't good quality, I don't want to do it. And I think what we were just talking about before the break is there's a complexity here that is really interesting and needs to be paid attention to. This is not just about qualities, it turns out. In fact, you know, quality of care during a video visit was not particularly related to preference to return to in-person visits for physicians.
00;16;09;20 - 00;16;29;07
Gillian SteelFisher
That is like those who felt that the quality of care was worse by video, they were no more likely than those who felt the quality was the same to say they wanted to return in-person. Right? So it wasn't like, oh, I'm just dissatisfied with what I can do for patients, you know, in fact, the only thing that was related of all those different features we looked at, right, we talked about this, all the fabric of the meeting and what happened, whatever.
00;16;29;08 - 00;16;53;18
Gillian SteelFisher
But the only thing that was really predictive was experiencing frequent technological challenges, like if your Internet just doesn't work, you just you want to go back to in-person work more likely, which totally makes sense, but it's not very revealing, right? And from a policy perspective, like, okay, well, we need to have better internet. Okay. Okay, that's interesting. But I think what it really means, right, is something more profound, right?
00;16;53;18 - 00;17;11;15
Gillian SteelFisher
Is that there may just be a more fundamental limitation in the appeal of telemedicine for primary care physicians as a mode of practice. Right? You know, and it's not, you know, when you think about it, right, we think about from a policy perspective, so technical, but there's a human dimension here as well, just like, you know, is this why people went to medical school?
00;17;11;15 - 00;17;35;13
Gillian SteelFisher
Is this what they hoped for in their practice? You know, are there tangible experiences of their working with patients that are motivating them, that are driving them? You know, sitting, you know, we talk about Zoom fatigue a lot in the context of the pandemic, and maybe this just needs to be thought of more broadly in the context of the way physicians are practicing and, you know, and that's really important.
00;17;35;13 - 00;17;44;02
Gillian SteelFisher
So I think that's been something that has been underappreciated and something we really need to get better consideration to on the physician side, for sure.
00;17;44;22 - 00;17;46;15
Alan Weil
What can you say on the patient side?
00;17;46;18 - 00;18;07;03
Gillian SteelFisher
Interestingly, the patients were a little bit reversed in the sense that they were a little closer to what I was predicting because maybe I’m a patient and that's why, but I don't think so. I think, you know, there was a little bit stronger preference to return to in-person care when they felt the quality was worse. Right? And it may be that their perception of what the quality is worse is a more composite measure or whatnot.
00;18;07;03 - 00;18;24;19
Gillian SteelFisher
But it was a little more what I expected. And there are technological challenges weren't that much of a predictor. So again, many patients are like, well, I got a technological challenge with everything, like meeting with my kid's teacher and meeting with my doctor and, you know, trying to, you know, go to work and do whatever else I'm doing.
00;18;24;19 - 00;18;46;27
Gillian SteelFisher
They're doing a lot of things over an online platform. And so it just wasn't a big driver, this sort of, it didn’t, relates specifically to their health care experience. So this was more about what they thought of the quality of care, which again, I think turns a little bit of the, you know, common thoughts about how patients perceive quality.
00;18;46;27 - 00;19;07;07
Gillian SteelFisher
So I think that's important to pay attention to as well. They are paying attention to quality and what they feel like they're getting out of these visits and their care. And I think we also, you know, extended some thinking about the kinds of patients that might be benefiting more from online care. You know, this was a survey we're asking all the people who had an online visit.
00;19;07;07 - 00;19;30;21
Gillian SteelFisher
Right? So everyone is technically online, but even then, we found that older respondents, those with less education and those who were Asian, were less likely to want to continue using video visits. And that makes me worry that there's other dimensions of the, you know, technological divide that we've been talking about for so long. It's not just access, right, it extends the online environment in ways that maybe we haven't appreciated.
00;19;30;21 - 00;19;41;22
Gillian SteelFisher
And, you know, in other words, I guess if you're getting on with your doctor, you might still not be on par, right? And so we need to really be mindful of that as well as we think about going forward.
00;19;43;08 - 00;20;11;06
Alan Weil
So when we started, you mentioned the dramatic policy shift, clearing out the barriers to using telemedicine. We are in a point in time where there are questions about whether those policies will be retained. And I think the premise of them has been, well, we need this modality to be available. When you think about the policy context, though, it does feel more complicated than that.
00;20;11;06 - 00;20;33;22
Alan Weil
Maybe we need it to be available, but we probably, if we listen to patients and primary care physicians, we probably don't need it to be dominant. So what do you think about the kind of policy environment that would be most supportive for the use of telemedicine given the preferences of those who are using it?
00;20;34;11 - 00;21;02;08
Gillian SteelFisher
Yeah, I think we need to think about a policy that supports an online environment from two perspectives. So one is that there are some doctors who want to practice primarily virtually or with a lot of, you know, online and video based care. And there are patients who want to or need to and would benefit from having access via video and might have trouble accessing in-person.
00;21;02;08 - 00;21;25;04
Gillian SteelFisher
So there's that portion of it. And then also from a public health perspective, you know, we would benefit from having a future health system that has at least a meaningful minority of care delivered virtually so that we can kind of call up more virtual care when needed. Right? Starting from nothing is really hard. Starting from small is much, much easier.
00;21;25;15 - 00;21;45;24
Gillian SteelFisher
And so allowing health departments to expand when needed, that sort of, you know, that possibility of like, just add water. We need that in a pandemic kind of response. And we want to facilitate that when we think about policies. And so I think we need to think about identifying areas where virtual visits are most helpful and support those.
00;21;45;24 - 00;22;06;11
Gillian SteelFisher
And, you know, some of that is self-selected. They're being driven by physicians who like the modality and patients who want and need it. But we might also think about support for types of care where, for example, the physical exam is not totally central. So I think about, okay, well, what kind of visits work well in the online environment? Building on those.
00;22;06;11 - 00;22;38;25
Gillian SteelFisher
And I think there are some policy areas to focus on. I think we think about places where physical exam is not critical, but don't lose it entirely. And so there's a sort of meshing of, well, do we also need support for technologies that can enhance that virtual exam? Automated blood pressure cups, oxygen monitors, you know, all of those tools, you know, electrocardiograms. Whatever can improve the actual kind of data exchange between the patient and physicians in a way that's useful for the physician and not stressful for the patient.
00;22;38;25 - 00;23;12;29
Gillian SteelFisher
And so we might need policies to help develop those, to help pay for them. That might be a piece we kind of build around and expand. We also of course, need to address the technological and connectivity challenges, better platforms, better training, more integration into current technologies that people are familiar with and becoming more familiar with. And I think one important thing that we need to consider is I think there's been a lot of discussion about getting everyone online, but as we now are moving some people further online, we don't want to exacerbate that digital divide.
00;23;12;29 - 00;23;34;02
Gillian SteelFisher
It's a crack in the new system. It’s a divide before and then once you get online, it's still a crack and it could split wider open. And so we need to think about improving online access and support in underrepresented communities, but also training support for patients who maybe feel less comfortable with technology, don't have the same access. And medical practices are going to need help.
00;23;34;02 - 00;23;57;20
Gillian SteelFisher
There was a huge amount that staff needed to do. There are resources they need to bring those patients on in a meaningful way. And we also need to be honest about the risk of potential age based or race based and ethnicity based discrimination within video care visits and take that to heart and really think about what that might look like and understand it specifically in the online context.
00;23;57;20 - 00;24;04;09
Gillian SteelFisher
So it's actually, I think, a pretty full agenda for trying to think about an effective hybrid health care system of the future. It's a lot to do.
00;24;05;07 - 00;24;27;24
Alan Weil
Well, there is a lot to do. Dr. SteelFisher, thank you so much for shining a light on this topic and particularly helping us understand that satisfaction doesn't necessarily translate or equate to preference. And the nuance here is very useful. I appreciate the work you've done in the area. Thank you today for being my guest on “A Health Podyssey”.
00;24;27;24 - 00;24;30;27
Gillian SteelFisher
Thanks so much for having me.