Patient perception and satisfaction with a smartphone-based teledermatology service initiated during the COVID-19 pandemic at a tertiary care hospital in North India

Plain Language Summary

Telemedicine is the use of a technology-based virtual platform for remote medical consultations and it can be particularly advantageous during disasters and public health emergencies in rendering medical services at remote locations. We conducted a telephonic survey to assess patient perception and satisfaction with our smartphone-based hybrid teledermatology service initiated during the COVID-19 pandemic. Two hundred and one patients were asked to respond to the Telemedicine Satisfaction Questionnaire and an additional six-item questionnaire and were also asked to give qualitative feedback and suggestions. The overall mean Telemedicine Satisfaction Questionnaire score was 4.20± 0.71, indicating that the patients were generally satisfied with teledermatology services. Some concerns that emerged in the qualitative feedback were about the care perceived as not being at par with physical consultations, difficulty in procuring medicines, lack of confidence on photographic diagnoses and the lack of a personal touch. Patients with urticaria (hives), those who were advised a change in treatment and those with improvement in their skin disease were more likely to be satisfied with teledermatology services according to our survey.

Introduction

Telemedicine is the use of a technology-based virtual platform to remotely deliver various aspects of health information, prevention, diagnosis and medical care. Telemedicine has been used by several medical specialties, and it can be particularly advantageous during disasters and public health emergencies in rendering medical services at remote locations.¹During the current COVID-19 pandemic when social distancing is emphasized and lockdowns have further reduced access to healthcare professionals, telemedicine is being increasingly used to deliver health care to patients. The CDC reported a 154% increase in telehealth visits in the United States during the last week of March 2020, compared with the same period in 2019.²

Dermatology, being a visual specialty, is particularly well suited to telemedicine. Moreover, in India, where qualified dermatologists are concentrated in and around urban areas, and roughly one dermatologist caters to a population of 1.3 lacs,³ teledermatology can be an effective tool to meet patient needs, particularly for those in rural areas. With the rising number of smartphone users in India, smartphone-based teledermatology can be a convenient way for patients to utilize teledermatology services. As of December 2019, more than 50 crore (about 37% of the population) Indians were using smartphones, a 15% increase from 2018.⁴ Smartphone use in rural India also rose from 9% in 2015 to 25% in 2018.⁵

Methods

This was a cross-sectional telephonic survey conducted at the department of Dermatology and Venereology of the All India Institute of Medical Sciences, New Delhi that caters largely to the population of North India, after obtaining approval from The Institute Ethics Committee. Patients ≥18 years of age who had received a teledermatology consult during December 2020 to April 2021 were included after they gave their verbal informed consent. They were interviewed telephonically within two weeks of their last teledermatology consultation, by an investigator (DY) not affiliated with our department at the time of the study. Before the interview commenced, all the participants were informed that the interviewer is no longer affiliated with our institute, and that their responses would not affect their future care. After noting the demographic, clinical and teleconsultation details, patients were administered the Telemedicine Satisfaction Questionnaire and an additional 6-item questionnaire. They were also asked to give their feedback regarding their perception and satisfaction with our teledermatology services and suggestions for improvement using a semi-structured interview guide. In cases where teleconsultation was provided to the primary caregiver instead of the patients themselves, the survey was administered to the primary caregiver. The telephonic interviews were recorded and transcribed verbatim.

Results

We provided 1274 teledermatology consultations from December 2020 to April 2021. Three hundred and sixty-six patients, recruited through convenience sampling, were contacted for the telephonic survey. Of these, 122 could not be contacted for the interview, 18 did not consent to participate in the study and 25 were excluded because they were less than 18 years of age. Data for the remaining 201 subjects appears below.

Satisfaction scores

The overall mean Telemedicine Satisfaction Questionnaire score was 4.20± 0.71 indicating that patients were generally satisfied with the teledermatology services. The mean scores of the three domains “quality of care provided,” “similarity to face-to-face encounter” and “perception of interaction” were 4.13± 0.75, 4.28± 0.70 and 4.40± 0.96, respectively. All except two items in the Telemedicine Satisfaction Questionnaire had a mean score ≥4 (agree or strongly agree): “as if met in person” (3.82± 1.19) and “healthcare is consistent” (3.99± 1.07). The highest score was for an item pertaining to saving time travelling to the hospital, with a mean score of 4.70± 0.58. An overall Telemedicine Satisfaction Questionnaire score ≥4 was recorded by 139 (69.2%) patients. One hundred and seventy one (85.1%) patients said that they would use telemedicine services again, while 168 (83.6%) patients reported being satisfied with the quality of telemedicine services.

Of the six additional questions, three had a mean score ≥4. The items with a score of <4 were related to “preference for telemedicine over going to hospital” (3.93± 1.23), “medical care being as good as going to hospital” (3.79± 1.23) and “not being able to see the doctor not reducing the quality of consultation” (3.83± 1.20). Figure 1 shows the mean scores and break-up of patient responses for all items of the Telemedicine Satisfaction Questionnaire and additional questions.

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Figure 1:

The mean scores and break-up of patient responses for all items of the Telemedicine Satisfaction Questionnaire and our additional questionnaire

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Discussion

Telemedicine was virtually non-existent in India but the COVID-19 pandemic has thrust it to the forefront of the healthcare delivery system. Our telemedicine services were started during the lockdown due to the COVID-19 pandemic as an expediential measure to help patients access health services. We chose smartphone-based teledermatology using WhatsApp messenger because of its wide reach and feasibility. Smartphone-based teledermatology does not need dedicated infrastructure and therefore could be useful in resource-poor settings. Though patient satisfaction with conventional teledermatology has been shown to be generally high, not many studies have evaluated patient satisfaction with smartphone-based teledermatology in detail.^8,9

Our results show a mean Telemedicine Satisfaction Questionnaire score of 4.20, suggesting that patients were largely satisfied with our teledermatology service. Earlier studies using a 5-point Likert scale have also reported comparable mean scores, ranging from 3.8 to 4.74. While some of these studies focused on patients in specific categories such as skin malignancies, cosmetic dermatology, acne or psoriasis, many included general dermatology patients like ours.^10-15 About 84% of the patients in our survey reported being satisfied overall with the quality of telemedicine services, while about 69% of patients recorded an overall Telemedicine Satisfaction Questionnaire score ≥4. Around 85% patients said that they would use teledermatology again, a marker of its perceived usefulness. These results are consistent with those of previous studies, where satisfaction rates ranged from 77% to 90%.^10,15-19 Time saved in travelling to hospital emerged as the most appreciated aspect (mean Telemedicine Satisfaction Questionnaire score 4.70; 96% patients agreed or strongly agreed). This has been highlighted in earlier studies as well.^20,21

Patients were generally happy with the ease and comfort of telecommunication and the clarity of their interactions with the doctor in our study. However, patients did miss seeing their doctor during the teleconsultations, as we contacted the patients using a voice call; the items pertaining to this aspect had the lowest scores. Having an option of video-call was suggested by some patients to enhance the quality of the teleconsultation. An earlier study by Williams et al. also reported patients expressing lower satisfaction with the absence of face-to-face contact with doctor.²²

Another important concern was regarding the quality of healthcare provided through teledermatology, as suggested by the low scores on the relevant items. Some of the reasons for this perception included not enough time spent on teleconsultation by the doctor, and perceived inability to convey all problems properly to the doctor and/or doubts if the doctor understood them. Still, about 70% (n=142/201) of our study patients preferred teleconsultations over hospital visits, and 66% (n=133/201) of them felt that medical care through teleconsultations was as good as going to the hospital, rates that were comparable to those in other studies.^20,22

Patients also lacked confidence in the photographic diagnoses and assessments made without physical examination and had concerns regarding the clarity of skin lesions on photographs. Similar concerns regarding accuracy were expressed by about half of the patients in a study (n=123) from Australia by Chee et al.²³ However, a recent study from Brazil reported high diagnostic accuracy (78% complete agreement with in-person examination, 8% partial agreement and 14% no agreement) for inflammatory dermatoses with store-and-forward teledermatology,²⁴ while a systematic review suggests that smartphone-based teledermatology may have a similar or better diagnostic concordance than that of store-and-forward method.²⁵

Unlike other medical specialties, photography of skin lesions is a unique and an integral part of teledermatology. Most of our patients did not express concerns regarding taking and sending the photographs (91%, n=183/201) or regarding privacy (90%, n=181/201). Williams et al. also reported that 85% of their 122 patients did not mind being photographed.²² On the other hand, 14% of patients refused photography citing social or religious reasons in a Saudi Arabian study (n=166) by Kaliyadan et al.⁹ while about 25% patients expressed concerns regarding privacy in the Australian study (n=123) by Chee et al.²³

Qualitative feedback gave us insights into a few more issues that troubled our patients. Though seen as convenient and saving both time and money, some patients found telemedicine to be more expensive as they had to purchase medicines that were earlier available free of cost at our hospital. There is only limited literature formally evaluating the cost-effectiveness of teledermatology, but most studies suggest that it may be more economical, especially when indirect costs (such as lost productivity) are factored in. It may be particularly cost-effective for certain patient populations, such as those who live in remote areas with poor access to healthcare.^26,27Another problem patients faced was finding the prescribed medications in their locality/hometown; it was easier to buy them from a medical store near the hospital when they came for a physical consultation. Further, SMS or WhatsApp prescriptions were not accepted by all chemists and online pharmacies, and there were difficulties in getting reimbursements for medications purchased using such prescriptions. Patient suggestions around these problems included having a physical consultation after every few teleconsultations, free home-delivery of medicines from the hospital pharmacy, and modifying e-prescriptions to make them look more authentic. These issues need the attention of healthcare policy makers for easier implementation of telemedicine services. Several countries have formulated regulations and have adopted e-prescription systems in community pharmacies at a national level.²⁸

There are a few studies that have looked at factors associated with patient satisfaction with teledermatology. Williams et al. found that patients with a high burden of disease did not prefer teleconsultations.²² Hsueh et al. reported short waiting times before teleconsultation, perception of skin disease being properly treated and receiving adequate follow-up as factors associated with patient satisfaction.¹⁵ A recent Indian study by Handa et al. reported higher satisfaction levels among patients with dermatophytoses, infestations and bacterial infections,²⁹ while dermatologists perceived superficial skin infections, acne, eczemas and pigmentary disorders to be particularly suited for telemedicine.^30,31 We found that patients with urticaria were more likely to be satisfied with teledermatology than those with other diagnoses, probably because the disease is seen as non-serious, assessment is largely based on patient history, and it is amenable to easy treatment titrations on teleconsultations. As expected, patients whose skin disease improved after the teleconsultations were more satisfied than those whose disease remained unchanged or worsened, while patients who were advised a change in treatment were also more satisfied. In general, patients who are advised a change in treatment plan may feel that their problems have been better attended, though this may not always be true. Similarly, in another study, patients who were only reassured were less satisfied than those who were advised a skin biopsy or a face-to-face evaluation.³² We noted a trend for better satisfaction in patients who had received more than one teleconsult, presumably because of increased familiarity with the process. We expected patients from outside the state and those with long travelling hours to the hospital to be more satisfied with teledermatology, but this was not the case in our results. Patient satisfaction was found to be independent of distance from hospital in the study by Handa et al. as well.²⁹ Younger and more educated patients are more likely to be at ease with new technology, and therefore more receptive of teledemedicine, but we did not find any association of patient satisfaction with age or education status.

Most of the earlier studies on patient satisfaction with telemedicine used non-validated instruments. We used the Telemedicine Satisfaction Questionnaire, a validated instrument developed for this purpose.⁷ As this was a general telemedicine instrument, we supplemented it with a few of our own questions particularly relevant to teledermatology. In addition, patient’s qualitative feedback and their suggestions were also collected.

Conclusion

Our results suggest that patients find telemedicine a convenient, time-saving and cost-effective alternative to physical hospital visits. Satisfaction levels were generally high with our smartphone-based teledermatology service. Our study identified certain lacunae that negatively impact patient perception and satisfaction; addressing them might help in greater acceptance of teledermatology services.