3.3.5.1.1. Care for Specific Conditions, Pregnancy/Prenatal/Gynecological Care

Among patients who received specialized care for pregnancy/prenatal/gynecological care, two observational studies reported mortality rates after an in-person versus a telehealth visit. One cross-sectional study with a moderate risk of bias assessed successful medical abortion rates among patients who received an in-person versus a telehealth medical abortion visit (mean age of 28 years). This study enrolled 22,158 patients who had in-person visits and 29,984 patients who had telehealth visits.⁹¹ The study identified no difference in mortality rates between the two groups (no deaths in the 59 days after the visit in the in-person group and no deaths in the 85 days after the visit in the telehealth group). A cohort study with a moderate risk of bias assessed neonatal intensive care nursery mortality rates for infants of patients who received in-person versus telehealth postpartum care (median age of 30.35 years). The study enrolled 780 patients who had in-person visits and 799 patients who had telehealth visits.⁷⁹ It identified slightly lower mortality rates among those who had an initial in-person visit (11 deaths [1.4 percent] among those in the in-person group versus 13 deaths [1.6 percent] among those in the telehealth group, p=0.72).

For patients who receive specialized pregnancy/prenatal/gynecological care, those who receive an initial telehealth visit may have similar mortality rates compared with those who receive in-person care (SOE: Low) (Table 6).

3.3.5.1.2. Care for Specific Conditions, Other Conditions

Among patients who received care for specific conditions, excluding COVID-19 and pregnancy/prenatal/gynecological care, three observational studies reported mortality rates after an in-person versus a telehealth visit. One study, a cohort study with critical risk of bias owing to substantial concerns about how time-varying confounders were addressed, was conducted in Portugal. This study assessed mortality rates among elderly patients with chronic heart failure (mean age of 71 years) and compared rates from the pre-COVID-19 era (mainly in-person visits) with rates from the COVID-19 era (mainly telehealth visits).⁶² The study identified a lower mortality rate among patients who had an initial telehealth visit (20 deaths among 160 patients in the in-person group [12.5 percent] versus 1 death among 43 patients in the telehealth group [2.3 percent]). The death events were assessed in the 497 days after the initial visit in the in-person group and in the 70 days after the initial visit in the telehealth group. A small sample size and a much shorter followup period for the telehealth group may have contributed to the detection of fewer death events in this group.

Table 6

Summary of findings: mortality for patients receiving telehealth versus in-person care (N=7 studies).

Figure 7

Forest plot presenting mortality outcomes for patients who had an initial telehealth visit versus an initial in-person visit. CI = confidence interval; N = sample size; NR = not reported; OBGYN = obstetrics and gynecology; OR = odds ratio.

The second study was a cohort study with a moderate risk of bias among older adults with heart failure (mean age of 71 years) enrolling 39 patients who had in-person visits and 43 who had telehealth visits.⁸⁰ The study identified lower mortality rates among those who had an initial telehealth visit (5.1 percent mortality rate among those in the in-person group versus 2.33 percent mortality rate among those in the telehealth group, p=0.60).

The third study, a cross-sectional study with serious risk of bias owing to lack of information on adjusting for confounders, was conducted in Australia. This study assessed mortality rates among adult and elderly patients with cancer (mean age of 62.77 years) and compared rates from the pre-COVID-19 era (mainly in-person visits) with rates from the COVID-19 era (mainly telehealth visits).⁶⁵ The study identified a slightly higher mortality rate among patients who had an initial in-person visit (7 death events among 814 patients [0.86 percent] in the in-person group versus 0 death events among 910 patients [0 percent] in the telehealth group in 30 days after the first visit, p=0.008). A short followup period may have resulted in the small difference in death events between the two groups. For patients who receive care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), those who receive an initial telehealth visit may have lower mortality rates compared with those who receive in-person care (SOE: Low) (Table 6).

3.3.5.1.3. Surgical Care

Among patients who received surgical care, two observational studies reported mortality rates after an in-person versus a telehealth visit. One cohort study with serious risk of bias, owing to concerns with confounders, assessed mortality rates among patients who underwent abdominal surgery (median age of 49 years) and had an in-person versus telehealth visit for post-operation followup. This study enrolled 113 patients who had in-person visits and 106 patients who had telehealth visits.⁶⁶ The study identified no difference in mortality rates between the two groups [0 death events among those in the in-person group versus 0 death events among those in telehealth group].

Another cohort study with moderate risk of bias assessed mortality rates among adult and elderly patients who underwent surgery (mean age of 56.6 years) and had an in-person versus telehealth visit for post-operation followup. This study enrolled 437 patients who had in-person visits and 98 patients who had telehealth visits.⁸⁶ The study identified higher mortality rates among those who had an initial telehealth visit compared with those who had an in-person visit [OR: 2.26; 95% CI, 0.48 to 7.72, p=0.32]. The study favoring in-person visits was larger and the mortality rates were assessed in the 90 days after the surgery, which may have contributed to the detection of a clinically meaningful difference between the two groups. For patients receiving surgical care, those who receive an initial telehealth visit may have higher mortality rates compared with those who receive in-person care (SOE: Low) (Table 6).

3.3.9.6.1. General Medical Care, All Ages

Among patients of all ages who received care for general medical conditions, two observational studies reported case resolution/duplication of services rates after an in-person or telehealth visit. One cross-sectional study, with serious risk of bias owing to concerns about potential confounders, among adults (median age of 26 years) reported the need for a followup visit with the health system for those who received an in-person, outpatient primary care visit versus those who received a telephone or video telehealth primary care visit.¹²⁴ This study identified higher rates of followup visits among those who had an initial telehealth visit than those with an in-person visit (e.g., mean number of followup telephone calls of 3.56, SD 2.46 in the in-person group versus 5.29, SD 2.6 in the telephone telehealth group and 4.39, SD 2.5 in the video telehealth group, p=0.002).

A cohort study with low risk of bias reported followup visits of any kind for patients with general medical care (all ages) with a diagnosis of acute or chronic ambulatory care sensitive conditions (i.e., conditions that would avoid healthcare utilization with proper ambulatory management of the disease). Among patients with acute ambulatory care sensitive conditions, the study analyzed claims data on 493,716 patients who had in-person visits and 113,857 patients who had telehealth visits.³ The study reported higher followup visit rates among those who had an initial telehealth visit than those who had an initial in-person visit (OR: 1.44; 95% CI, 1.42 to 1.46, with in-person visit as the reference). Among patients with chronic ambulatory care sensitive conditions, the study analyzed claims data on 410,743 patients with in-person visits and 94,481 patients with telehealth visits, reporting lower followup visit rates among those who had an initial telehealth visit than those who had an initial in-person visit (OR: 0.94; 95% CI: 0.92 to 0.95, with in-person visit as the reference). The study only identified followup visits that occurred within 14 days after the initial visit, which may have contributed to the modest difference between the two groups.

The two studies showed conflicting results. The difference in the type of clinical conditions that the studies assessed may have resulted in the conflicting results between the two studies. The study favoring telehealth care for a sub-population of patients (lower rates of followup visits for patients with chronic ambulatory care sensitive conditions)³ was larger and assessed followup visits separately for those with acute and chronic ambulatory care sensitive conditions, which may have resulted in more accurate parsing out of the difference in followup visit patterns. For patients of all ages who receive care for general medical conditions, those who receive an initial telehealth visit for an acute condition may have higher rates of followup visits compared with those who receive in-person care, and those who receive an initial telehealth visit for a chronic condition may have lower rates of followup visits compared with those who receive in-person care (SOE: Moderate) (Table 11).

Table 11

Summary of findings: case resolution/duplication of services for patients receiving telehealth versus in-person care (N=12 studies).

Figure 12

Forest plot presenting case resolution for patients who had an initial telehealth visit versus an in-person visit. CI = confidence interval; N = sample size; NR = not reported; OBGYN = obstetrics and gynecology; OR = odds ratio.

3.3.9.6.2. Care for Specific Conditions, COVID-19

One cohort study, with serious risk of bias owing to concern about the handling of confounders and missing data, assessed case resolution/duplication of services among patients with COVID-19 (mean age of 39 years) after an in-person or telehealth visit.⁸⁷ The study reported lower rates of followup visits (i.e., duplication of services) among those who had an initial telehealth visit (7 of 132 patients [5.3 percent] in the in-person group versus 6 of 153 patients [3.9 percent] in the telehealth group returned to the health system in the 72 hours following the initial assessment). The short followup period may have resulted in the detection of fewer followup events in both groups. Owing to the limited number of studies, small sample size, and concerns with risk of bias, there is insufficient evidence that patients who receive an initial telehealth visit may have different rates of case resolution and followup visits compared with those who receive in-person care (SOE: Insufficient) (Table 11).

3.3.9.6.3. Care for Specific Conditions, Pregnancy/Prenatal/Gynecological Care

One cohort study with a moderate risk of bias among patients in a family planning clinic (mean age of 28 years) assessed case resolution/duplication of services among those who received an in-person or telehealth medical abortion service. This study enrolled 94 patients who had in-person visits, 124 patients who had telehealth visits and picked up their medication from the clinic, and 69 patients who had telehealth visits and received their medication in the mail.⁶⁰ The study reported higher rates of case resolution (i.e., completed medical abortion with no need for surgery) among those in the telehealth group compared with those in the in-person group (88 of 94 patients [93.6 percent] who received an in-person visit versus 120 of 124 patients [96.8 percent] who received a telehealth visit and picked up their medication from the clinic and 67 of 69 patients [97.1 percent] who received a telehealth visit and received their medication in the mail). The small sample size across the three groups may have resulted in small differences in case resolutions among them. Owing to the limited number of studies, small sample size, and some concerns with risk of bias, there is insufficient evidence that those who receive an initial telehealth visit may have different rates of case resolution compared with those who receive in-person care (SOE: Insufficient) (Table 11).

3.3.9.6.4. Care for Specific Conditions, Other Conditions

Among patients who received care for specific conditions, excluding COVID-19 and pregnancy/prenatal/gynecological care, seven observational studies reported case resolution/duplication of services after an in-person or telehealth visit.

Three studies reported findings favoring in-person visits. One was a cohort with a serious risk of bias owing to concerns with confounders. This study assessed followup telephone visits among rheumatology patients (mean age of 55 years old).⁸² The study reported a lower rate of followup phone calls among patients who had an initial in-person visit compared with those who had a telehealth visit (29 of 1,286 patients [2.3 percent] in the in-person group versus 48 of 1,493 patients [3.2 percent] in the telehealth group, p=0.13). Another cohort study, with serious risk of bias owing to concerns about confounding and intervention classification, among adult patients (median age of 67 years) in a cardiology clinic, assessed the need for followup appointments after an in-person or telehealth visit.⁵⁴ This study identified a lower rate of followup appointments among those who received in-person visits (196 of 1,118 patients [16.5 percent] in the in-person group versus 79 of 327 patients [24.2 percent] in the telehealth group, p=0.015). The difference in followup visit rate was much larger in one study than in the other. Different patient populations and clinical conditions, as well as different followup periods, might have resulted in this wide range of followup visits between the two studies. A third cohort study, with serious risk of bias owing to concerns with adjusting for confounders, was conducted in Sweden. This study assessed unplanned telephone contact with the physician among adult and elderly patients with inflammatory bowel disease (mean age of 47.6 years) and compared data from the pre-COVID-19 era (mainly in-person visits) with data from the COVID-19 era (mainly telehealth visits).¹¹⁴ The study reported a slightly higher number of unplanned telephone contacts among patients who had an initial telehealth visit (mean of 0.88; SD 1.89 contacts per patient among 814 patients in the in-person group versus mean of 0.9; SD 1.9 contacts per patient among 910 patients in the telehealth group, p=0.379).

Four studies reported findings in favor of telehealth visits. One was a cohort study, with serious risk of bias owing to concerns with adequate adjustment for confounders, among children with epilepsy (mean age not reported) enrolling 101 patients who had in-person visits and 16 patients who had telehealth visits.¹⁰⁰ The study reported a higher rate of case resolution among those who had an initial telehealth visit (75 percent of patients in the in-person group required a followup counseling visit in the 1 month after the initial visit versus 35 percent of patients in the telehealth group) and the difference was clinically meaningful. The much smaller sample size in the telehealth group compared with the sample size in the in-person group might have resulted in the identification of a smaller number of patients with followup visits in the telehealth group. The second study was a cohort study, with serious risk of bias owing to concerns with inadequate adjustment for confounders, among children in an otolaryngology clinic (mean age of 24 months) enrolling 50 patients who had in-person visits and 50 patients who had telehealth visits.¹²⁵ This study identified lower rates of recommended followups among those who had an initial telehealth visit compared with those who had an initial in-person visit (16 followup visits [32 percent] among those in the in-person group versus 10 followup visits [20 percent] among those in telehealth group, p=0.25). The third study, a cohort study with serious risk of bias owing to concerns with inadequate adjustment for confounders, was conducted in an eye hospital. This study assessed the need for an in-person ophthalmology assessment among patients who were triaged in-person or via telehealth for an ophthalmic issue (median age of 49 years).¹²⁶ The study identified a lower rate of followup visits among patients who had an initial telehealth visit (40 followup visits among 451 patients [88.7 percent] in the in-person group versus 220 among 403 patients [54.6 percent] in the telehealth group, p<0.001). The fourth study, a cohort study with serious risk of bias owing to concerns with adjusting for confounders and patient selection, was conducted among patients with cardiac diseases in Ireland. This study assessed the return to clinic among adult and elderly patients who received in-person care (N=1,220) or telehealth care (N= 496) (mean age of 60 years).¹²⁷ The study reported a lower rate of return to clinic among patients who had an initial telehealth visit (980 patients [80.3 percent] in the in-person group versus 353 patients [71.2 percent] in the telehealth group, p=0.0003).

Studies varied in their patient populations and clinical conditions, which may have resulted in this wide range of followup visits among the studies. Although three studies showed higher case resolution in the in-person group, the four studies favoring telehealth presented more consistent results and clinically meaningful differences between the two groups (Table 11). For patients who receive care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), those who receive an initial telehealth visit may have higher rates of case resolution and a lower rate of duplicated services compared with those who receive in-person care (SOE: Low).

3.3.9.8.1. General Medical Care, Adults

Among adult patients who received care for general medical conditions, two observational studies reported changes in therapy/medication after an in-person or telehealth visit. One cohort study, with low risk of bias conducted in Australia, assessed change in therapy/medication among adult and elderly patients who received professional general practitioner consultations for standard attendance, chronic disease management, and/or mental health service in an in-person (N=8,303,233) or telehealth visit (N=5,304,983).¹²⁸ This study reported higher rates of change in medication among patients who had an initial in-person visit, compared with patients who had a telehealth visit, presented as the number of consultations with at least one prescribed medication (3,264,748 patients [39.3 percent] in the in-person group versus 1,751,878 patients [33 percent] in the telehealth group, OR: 1.38; 95% CI, 1.379 to 1.381). Another cohort study with moderate risk of bias assessed change in therapy/medication among adult and elderly patients (mean age of 62.52 years) who had an in-person (N=341) or telehealth pharmacy visit (N=151).¹⁰⁸ This study reported higher average additional or different medications per visit among patients who had an initial in-person visit than among those who had a telehealth visit (mean: 0.37; SD 0.7 in the in-person group versus 0.12; SD 0.4 among patients in the telehealth group, p=0.527 for needing additional medications and mean: 0.09; SD 0.31 in the in-person group versus 0.06; SD 0.23 among patients in the telehealth group, p=0.423 for needing different medications). The two studies were different in their patient populations and clinical conditions. For adult patients receiving general medical conditions, patients who receive an initial in-person visit may have higher rates of change in therapy/medication compared with those who receive telehealth care (SOE: Moderate) (Table 12).

Table 12

Summary of findings: change in therapy/medication for patients receiving telehealth versus in-person care (N=8 studies).

Figure 13

Forest plot presenting change in therapy outcomes for patients who had an initial telehealth visit versus an in-person visit. CI = confidence interval; N = sample size; NR = not reported; OBGYN = obstetrics and gynecology; OR = odds ratio.

3.3.9.8.2. Care for Specific Conditions, Other Conditions

Among patients who received care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), six observational studies reported changes in therapy/medication after an in-person or telehealth visit.

One cohort study with moderate risk of bias assessed changes in therapy/medication among rheumatology patients (mean age of 55 years).¹⁰¹ This study reported a higher rate of change in therapy/medication among patients who had an initial in-person visit (22 of 210 patients [10.5 percent]) compared with patients who had an initial telehealth visit (20 of 340 patients [5.9 percent]) for those patients who had a new disease-modifying antirheumatic drug started for them, with the following difference in proportion: −0.05 (95% CI, −0.1 to 0, p>0.05); the study also reported a higher rate of change in therapy/medication among patients who had an initial in-person visit (12 of 210 [5.7 percent] and patients who had an initial telehealth visit (11 of 340 [3.2 percent]) for those patients who had an increase in the dose of their disease-modifying antirheumatic drug, with the following difference in proportion: −0.02 (95% CI, −0.07 to 0.01, p>0.05).

Another cohort study, with a serious risk of bias owing to concerns regarding inadequate adjustment for confounders, assessed changes in therapy/medication among rheumatology patients (mean age of 55 years).⁸² The study reported a higher rate of change in therapy/medication among patients who had an initial in-person visit compared with those who had a telehealth visit (352 of 1,286 patients [27.4 percent] in the in-person group versus 338 of 1,493 patients [22.6 percent] in the telehealth group had a change in their immunosuppressive therapy, p=0.004, and 96 of 1,286 patients [7.5 percent] in the in-person group versus 79 of 1,493 patients [5.3 percent] in the telehealth group had a change in their analgesic medication, p=0.019).

The third study, a cohort study with serious risk of bias owing to inadequate reporting for adjustment of confounding factors, assessed change in therapy/medication among adult patients with irritable bowel syndrome (age range from 22 to 76 years; median age of 36 years).⁸¹ This study reported a higher rate of change in therapy/medication among patients who had an initial telehealth visit (19 of 50 patients [38 percent] in the in-person group versus 29 of 45 patients [64 percent] in the telehealth group had a biologic agent started for them, p=0.01; and, 8 of 50 patients [16 percent] in the in-person group versus 8 of 45 patients [18 percent] in the telehealth group had a dose escalation in their medication, p>0.99.)

The fourth study, a cohort study with serious risk of bias owing to concerns with adjusting for confounders and patient selection, was conducted in Ireland among patients with cardiac diseases. This study assessed changes in medication or management of disease among adult and elderly patients who had an initial in-person visit (N= 1,220) or telehealth visit (N= 496) (mean age of 60 years old).¹²⁷ This study reported a higher rate of change among patients who had an initial in-person visit (470 patients [38.5 percent] in the in-person group versus 99 patients [19.9 percent] in the telehealth group had at least one change in the clinical management of their disease, p=<0.00001, and 390 patients [31.9 percent] in the in-person group versus 80 patients [16.1 percent] in the telehealth group had a medication change, p=<0.00001).

The fifth study, a cohort study with serious risk of bias owing to concerns about addressing confounders, was conducted among patients with inflammatory bowel disease and assessed changes in medication or management of disease among adult patients who had an initial in-person visit (N= 868) or telehealth visit (N= 891) (mean age of 47.6 years old).¹¹⁴ The study reported a higher rate of change in medication among patients who had an initial telehealth visit (21.3 percent in the in-person group versus 22.2 percent in the telehealth group had a medication increase, p=0.641; 6.1 percent in the in-person group versus 5.9 percent in the telehealth group had a medication decrease, p=0.914; and 76.1 percent in the in-person group versus 75.3 percent in the telehealth group had no change in medication, p=0.713). The difference between the two groups was small and clinically not meaningful.

The sixth study was a cohort study, with serious risk of bias owing to concerns about addressing confounders, conducted in Spain. This study assessed the mean number of prescribed medications among patients with multiple sclerosis (mean age not reported).¹²⁹ The study reported a higher number of prescribed medications among patients who had an initial in-person visit (mean of 30.0, SE 7 among patients in the in-person group versus mean of 23.2, SD 5.5 among patients in telehealth group, p=0.805). The difference was small and not clinically meaningful.

The six studies were different in their patient populations, clinical conditions, and the type of treatment/medication. One of the studies favoring telehealth was conducted in the later months of the pandemic (January 1 to May 31, 2021) when telehealth utilization was stabilized across healthcare systems.¹²⁹ Four of the studies showing a lower rate of change in therapy or medication in the telehealth group were larger studies, with one study assessed as a moderate risk of bias. For patients who receive care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), those who receive an initial telehealth visit may have lower rates of change in therapy/medication compared with those who receive in-person care (SOE: Low) (Table 12).

3.3.9.9.1. General Medical Care, Adults

Among adult patients who received care for general medical conditions, two observational studies reported therapy/medication adherence after an in-person or telehealth visit.

Table 13

Summary of findings: therapy/medication adherence for patients receiving telehealth versus in-person care (N=9 studies).

Figure 14

Forest plot presenting treatment adherence for patients who had an initial telehealth visit versus an in-person visit. CI = confidence interval; N = sample size; NR = not reported; OBGYN = obstetrics and gynecology; OR = odds ratio.

A cohort study, with serious risk of bias owing to lack of proper adjustment for confounders and handling of missing data, assessed therapy/medication adherence among younger, mostly White females in the United States (mean age of 38 years).⁷⁷ This study identified a higher rate of therapy/medication adherence among patients who had an initial telehealth visit (129 of 207 patients [62.3 percent] in the in-person group versus 151 of 207 patients [72.9 percent] in the telehealth group, p<0.05), and the difference was clinically meaningful.

Another cohort study with moderate risk of bias assessed therapy/medication adherence among adult and elderly patients (mean age of 62.52 years) who had an in-person (N=341) or telehealth pharmacy visit (N=151).¹⁰⁸ This study reported that the average therapy/medication adherence per visit among patients who had an initial in-person visit was the same as those who had a telehealth visit (mean: 0.01; SD 0.14 for non-adherence in the in-person group versus 0.01; SD 0.08 among patients in the telehealth group, p=1). Between the two studies, the study favoring a telehealth visit identified a large and clinically meaningful difference between the two groups. For adult patients receiving care for general medical conditions, patients who receive an initial telehealth visit may have higher rates of therapy/medication adherence compared with those who receive in-person care (SOE: Low) (Table 13).

3.3.9.9.2. Care for Specific Conditions, Other Conditions

Among patients who received care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), four studies assessed therapy/medication adherence after an in-person or telehealth visit. A cohort study, with moderate risk of bias, assessed therapy/medication adherence (i.e., continuous positive airway pressure [CPAP] compliance) among patients with sleep apnea (mean age not reported).¹³⁰ This study reported similar rates of CPAP compliance among 193 patients in the in-person group and 77 patients in the telehealth group (p=0.099).

A second cohort study, with moderate risk of bias, assessed therapy/medication adherence among adult and elderly patients with diabetes (mean age of 62 years) who had an initial in-person (N= 54,872) or telehealth (N= 8,850) visit.¹³¹ This study reported higher rates of medication adherence among those in the in-patient group (33,053 patients [60.2 percent] in the in-person group versus 4,960 patients [56 percent] patients in the telehealth group p=<0.001). The medication adherence rates were also slightly higher among patients with and without type 2 diabetes who had an initial in-person visit (19,775 patients [68.1 percent] in the in-person group versus 2,904 patients [60.2 percent] patients in the telehealth group, p=<0.001, among those with type 2 diabetes; and 13,278 patients [51.4 percent] in the in-person group versus 2,056 patients [51 percent] patients in the telehealth group, p=0.64, among those without type 2 diabetes). The outcomes were assessed 6 months after the initial visits.

The third cohort study, with low risk of bias, assessed the adherence to inhaled corticosteroids, which was defined as the proportion of days covered (a proportion between 0.0 and 1.0) among adult and elderly patients with asthma (mean age not reported).⁶⁴ The study reported slightly higher adherence among patients who had an initial telehealth visit (mean of 0.446, SE 0.008 among 1,792 patients in the in-person group versus mean of 0.476, SE 0.008 among 1,952 patients in the telehealth-only group, p comparing the two groups not reported). The difference was small and not clinically meaningful.

The fourth study was a cross-sectional study, with serious risk of bias owing to concerns with addressing confounders, that reported the number of physician recommended surgeries that were completed after a telehealth or in-person visit among pediatric otolaryngology patients (mean age of 6.15 years).¹³² The study reported a slightly higher adherence to physician recommendation among patients who had an initial telehealth visit (41 patients [36.3 percent] in the in-person group vs 24 patients [40.7 percent] in the telehealth group, p-value not reported).

The four studies were different in their patient populations, clinical conditions, and the type of treatment/medication. They also used different definitions of medication adherence. The study favoring in-person visits had a much larger sample size and the difference between two groups in the whole population was slightly bigger than the other studies.¹³¹ For patients who receive care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), those who receive an initial telehealth visit may have lower rates of therapy/medication adherence compared with those who receive in-person care (SOE: Low) (Table 13).

3.3.9.11.1. Care for Specific Conditions, Pregnancy/Prenatal/Gynecological Care

Among patients who received specialized pregnancy/prenatal/gynecological care, one cohort study, with moderate risk of bias, assessed completion of postpartum glucose tolerance test among patients with diabetes who received in-person (N= 45) or telehealth (N= 59) postpartum care (median age of 30.35 years).⁷⁹ The study reported slightly lower rates of completed glucose tolerance test among patients who had an initial telehealth visit compared with those who had an in-person visit (12 patients [26.7 percent] among those in the in-person group versus 15 patients [25.4 percent] among those in the telehealth group, OR: 0.99; 95% CI: 0.37 to 2.68, p=0.89), but the difference was not clinically meaningful. For patients receiving specialized pregnancy/prenatal/gynecological care, those who receive an initial telehealth visit may have similar rates of up-to-date labs and paraclinical assessment compared with those who receive in-person care (SOE: Low) (Table 14).

3.3.9.11.2. Care for Specific Conditions, Other Conditions

Among patients who received care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), six observational studies reported rates of up-to-date labs and paraclinical assessment after an in-person or telehealth visit.

One cohort study, with serious risk of bias owing to concerns about handling confounders and missing data, included patients in a diabetes care center (mean age of 37 years).¹³⁵ Patients in the telehealth group had a higher rate of continuous glucose monitoring compared with those in the in-person group (7 of 43 patients [16 percent] in the in-person group versus 155 of 166 patients [93.4 percent] in the telehealth group, p<0.001).

A second study was a cohort study, with serious risk of bias owing to concerns about handling confounders and missing data, among patients in a gastroenterology/rheumatology clinic (mean age of 55 years).¹³⁶ Patients in the in-person group had a higher rate of completion of pathology consults and radiology assessments ordered for them compared with those in the telehealth group (426 of 492 patients [86.6 percent] in the in-person group versus 443 of 582 patients [76.1 percent] in the telehealth group completed their pathology consult, p<0.001; and 247 of 295 patients [83.7 percent] in the in-person group versus 229 of 345 patients [66.4 percent] in the telehealth group completed the radiology assessment, p<0.001), and the difference between the two groups was clinically meaningful.

The third cohort study, with serious risk of bias owing to issues with addressing confounders, assessed up-to-date labs and paraclinical assessment among adult and elderly patients with cancer (median age of 60 years) compared the care prior to (N= 763) and during transition to telehealth (mainly in-person visits) (N=168) with the post-transition period (mainly telehealth visits) (N= 813).⁶³ The study reported a lower rate of up-to-date labs and paraclinical assessment among patients who had an initial visit in 1 week during the transition and in 4 weeks after the transition compared with those who had an initial visit in 4 weeks prior to the transition (265 patients [34.7 percent] in the pre-transition group versus 58 patients [34.5 percent] in the during transition group and 105 patients [12.9 percent] in the post-transition group, p=<0.0001, for up-to-date laboratory testing; 112 patients [14.7 percent] in the pre-transition group versus 17 patients [10.1 percent] in the during-transition group and 40 patients [4.9 percent] in the post-transition group, p=<0.0001, for up-to-date diagnostic imaging; and 16 patients [2.1 percent] in the pre-transition group versus 1 patient [0.6 percent] in the during-transition group and 5 patients [0.6 percent] in the post-transition group, p=0.0223, for up-to-date procedures such biopsy, paracentesis, acupuncture, endoscopy, and catheter exchanges).

The fourth cohort study, with serious risk of bias owing to concerns with addressing confounders, was conducted in Spain. This study assessed the completion of magnetic resonance (MR) scan among patients with multiple sclerosis (mean age not reported).¹²⁹ The study reported higher monthly number of MR scans performed among patients who had an initial in-person visit versus patients who had telehealth care (mean of 196, SD 17.5 among patients in the in-person group versus mean of 183.5, SD 68.9 among patients in telehealth group, p=0.538).

The fifth study, a cross-sectional study with serious risk of bias owing to concerns with patient selection, assessed the number of lab and imaging orders placed in the system for adult patients with chest pain (median age of 44 years) in primary care clinics during the COVID-19 era.⁸⁵ The study identified similar rates of placed orders between the two groups (median of 1; interquartile rate (IQR): 0 to 1 for imaging in the in-person group versus median of 1; IQR: 1 to 1 in the telehealth group, p=0.006; and median of 6; IQR: 4 to 8 orders for labs in the in-person group versus median of 6; IQR: 5 to 8 in the telehealth group, p=0.02). But it did not report the completion rates of the placed orders between the two groups.

The sixth study was a cohort study with serious risk of bias owing to concerns with confounders that assessed the proportion of inflammatory bowel disease patients with surveillance or activity control colonoscopies (mean age of 47.6 years).¹¹⁴ The study reported a higher proportion of surveillance colonoscopies performed among patients who had an initial in-person visit (76 of 814 patients [15 percent] in the in-person group versus 49 of 910 patients [9.4] in the telehealth group, p=0.007).

The six studies were different in their patient populations, clinical conditions, and the type of lab/paraclinical assessment. For patients receiving care for specific conditions (excluding COVID-19 and pregnancy/prenatal/gynecological care), those who receive an initial telehealth visit may have lower rates of up-to-date labs and paraclinical assessment compared with those who receive in-person care (SOE: Low) (Table 14).

3.4.2.1.1. Telehealth Literacy

Three qualitative studies conducted in the United States, Canada, and Australia described the patient perspective, highlighting the limitations of using technology as a barrier to use,¹³⁷ as well as general lack of skill reducing the comfort level of using newer technology.¹³⁸ Specifically, two studies highlighted that older individuals may have difficulty with new technology.^{138, 139}

A small survey of 34 patients in the United States identified telehealth as convenient and well-integrated, with a few survey respondents noting that the system was unnecessarily complex.¹⁴⁰ The survey data differ from the qualitative data in that the populations are from different countries; the survey included heart failure patients versus general care in the qualitative study; and the qualitative data were collected in the later COVID-19 era, whereas the survey data were collected during the general COVID-19 era (Appendix C, Results Table D.11).

We have high confidence, based on three studies with minor methodological concerns, that telehealth literacy among patients is a barrier to care. This statement is supported by a survey with similar results (Appendix C, Results Table C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.1.2. Cost

No studies described cost from the perspective of patients as a barrier or a facilitator to telehealth.

3.4.2.1.3. Privacy

Seven qualitative studies described issues of privacy from patient perspectives. Patients raised concerns about confidentiality and privacy during the virtual visit,^141–147 describing concerns about not having caller ID, being overheard, and issues of background noise. Because of these types of noted issues, there was a preference for telephone consultations that would allow patients to write notes.

Two surveys of patients noted shorter waiting periods, and participants felt that their privacy was secured and respected.^{148, 149} The survey data may differ from the qualitative data as the specific type of telehealth was not reported in the surveys; patient conditions or clinical needs were different between the two types of studies; and the qualitative data were collected primarily during the early and general COVID-19 eras, whereas the surveys were conducted in the early COVID-19 era (Appendix C, Results Table C.3.).

Table 17

Summary of the evidence for patient perspectives of barriers and facilitators (N=23).

We have moderate confidence, based on the seven qualitative studies, that issues surrounding privacy are a patient-perceived barrier to care via telehealth. Our confidence is not high owing to the limited information available across the studies and the overall heterogeneity of the populations (Appendix C, Results Table C.4; Appendix D, Evidence Table D.22; Table 17). Information collected from surveys, in contrast, suggests that privacy is not a patient-perceived barrier to care via telehealth.

3.4.2.1.4. Health Outcomes

Five qualitative studies described health outcomes associated with telehealth from the patient perspective. Patients felt that telehealth compromised their healthcare by letting their care “fall through the cracks” as a result of not having a physical exam, missed diagnoses, and discomfort discussing symptoms over the telephone.^{143, 151, 152} Patients expressed concerns about possible disease progression,¹⁴² citing challenges with remote assessment that included decreased clinical monitoring and ability to develop rapport – both of which could undermine the therapeutic relationship, exacerbate ‘secretive’ disorders (e.g., anorexia nervosa), and decrease overall clinical efficacy.¹⁵³

There were no surveys of patients that collected data about telehealth as being a barrier or facilitator to better health outcomes.

We have moderate confidence that patients perceive telehealth as a barrier to improved health outcomes. Our confidence is limited owing to inadequate description of qualitative methods in 40 percent of the studies, as well as the overall heterogeneity of the populations (Appendix C, Results Table C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.1.5. Communication

Six qualitative studies addressed communication barriers and facilitators from the patient perspective. When compared with in-person evaluations, patient participants cited communication via telehealth as limited^{142, 147} and not as effective or resulting in reduced confidence in the provider’s expertise.¹³⁷ In particular, patients perceived telehealth as less thorough and more rushed¹⁴⁷ and impersonal.¹⁵⁵ Patients reported difficulties building rapport, especially via telephone, owing to the lack of eye-to-eye contact and physical examination,¹⁴² and they expressed dislike for the formality of telephone appointments and the lack of nonverbal communication.¹⁵⁴ Patients described facilitators, such as the use of video conferencing, as more beneficial than a telephone appointment, as it allows the use of nonverbal communication.¹⁵⁴ Patients valued the ‘step-by-step’ approach staff took in explaining the process; they also emphasized that it was important that information be presented clearly, without the use of medicalized language, and that ample time be provided to ask questions.¹⁵⁰

One survey¹⁷⁶ noted that, when accessing telehealth, patients felt they had a better understanding of their need for a consultation and had adequate opportunity to discuss their concerns with the doctor. This survey differs from the qualitative studies in that the intervention was via telephone, only, rather than via telephone plus video. Populations also differed between this survey and the qualitative studies with the survey data focused on older (65+ years) patients (Appendix C, Results Table C.3).

We have high confidence that telehealth can act as both a barrier and a facilitator to communication from a patient perspective. We have minor concerns related to the adequacy of the findings in the studies, as well as the possibly skewed population providing input on outcomes in one study; however, we did not feel that these concerns sufficiently biased the findings in this area (Appendix C, Results C.4; Appendix D, Evidence Table D.22; Table 17). The survey pointed to telehealth having a positive impact on communication between patients and providers.

3.4.2.1.6. Technical Issues

We identified nine qualitative studies that addressed technical issues. From the patient perspective, technology-related barriers^{137, 147, 155, 158} included joining the online appointment¹⁵⁹ and utilizing the technology.^{142, 160} Patients felt intimidated by the technology; many were concerned that online technological aspects would be too difficult, ¹⁵⁶ and this was further affected by the abrupt transition to telehealth.¹⁵⁷ Other issues that patients noted were difficulties obtaining prescriptions and pathology results, reduced confidence in the doctor, and an added burden for complex medical care.¹³⁷ Other patient groups described issues with having to take their own vitals or an overall preference for in-person visits.¹⁴⁰ Concerns specific to the method of telehealth included feeling that communication was not as effective,¹³⁷ feeling like it was hard to hear during the appointment,¹⁴² and lack of access to the Internet or a video-conferencing device.¹⁴²

Fourteen surveys provided patient perspectives on technical issues with telehealth.^{140, 149, 176–187} Although many participants rated video and audio quality as “good,” greater than 15 percent of populations surveyed were neutral-to-negative about video and audio quality.^{149, 180, 181} One survey reported that 28 percent of the participants required technical assistance with the telehealth visit.¹⁸⁴ The survey data are similar to the qualitative data in that video (audio-visual appointments) was the primary mode of delivery and at least half of the data were from a U.S. population. However, the survey and qualitative data differ in patient health concern (Appendix C, Results Table C.3).

We have moderate confidence that patients perceive technical issues as a barrier to telehealth care. There was a lack of methodologic rigor and description of findings across studies, resulting in a lack of clarity about and confidence in the findings. Additionally, there was overall heterogeneity of the populations (Appendix C, Results Table C.4; Appendix D, Evidence Table D.22; Table 17). Information collected via patient survey supported the finding that technical issues can be a barrier to telehealth care from the patient perspective.

3.4.2.1.7. Inequity

We identified five qualitative studies that addressed inequity and its impact on access to telehealth care. Access was noted as problematic by patients with low socio-economic status or those lacking adequate resources, such as a stable internet connection.^{143, 157, 188} One study pointed to technology experience and lack of support surrounding it as an issue.¹⁸⁸ These issues were especially problematic for specific subgroups, presenting an issue of health equity.^{141, 142} These subgroups included vulnerable populations, those with digital literacy problems, older adults, and non-native English speakers.^{143, 174}

Two surveys^{178, 183} asked patients about telehealth access inequity. One survey highlighted that, while most patients have access to laptops, smartphones, or other devices that are video conference compatible, patients who are retired (i.e., older) have less access to these devices.¹⁷⁸ The other survey reported that patients often opt for telephone rather than video visits owing to a lack of access to video-capable devices.¹⁸³ These surveys differ from the qualitative studies in the populations studied. Additionally, all qualitative data were gathered in the early COVID-19 era, whereas survey data were collected in both the early and later COVID-19 eras. When reported, the mode of telehealth delivery was audio-visual for nine of the 15 surveys, and six of the qualitative studies (Appendix C, Results Table C.3).

We have moderate confidence that access to telehealth is problematic for patients in specific subgroups, including those of low socioeconomic status, vulnerable populations, older adults, and non-native English speakers. There were poor descriptions of qualitative data collection and analyses and heterogeneity in the populations studied (Appendix C, Results Table C.4; Appendix D, Evidence Table D.22; Table 17). Information collected via patient surveys supports our conclusion that access to telehealth can be a source of inequity.

3.4.2.1.8. Suggestions

We identified five qualitative studies from the patient perspective that included suggestions for better telehealth implementation, including greater technology integration support, as well as a provision for larger screens or better bandwidth.^{163, 164} Providing technical instruction or assistance to improve adoption of virtual care for elderly clients and others who struggled with this technology was suggested,¹⁵⁷ as was training for staff so they could provide support to patients.¹⁵⁷ Mental health and physical health were noted as important to patients, particularly for pre-, ante-, and postnatal populations; this population in particular felt that mental health was not addressed well by telehealth, and suggested that mental health care be included as a standard of care during telehealth visits.¹⁶⁵ Further, some patients receiving mental health prior to the COVID-19 era wanted additional online services, such as group therapy via video and more options for online counseling.¹⁵⁸

There were no surveys that collected patient suggestions on telehealth implementation.

We have moderate confidence that patients provided suggestions that are useful for better telehealth implementation. We had concerns with poor reporting of methodology and descriptions of findings. Additionally, there is overall heterogeneity of the populations studied (Appendix C, Results C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.1.9. Advantages

Four qualitative studies identified some of the positive aspects of telehealth noted by patients: improved access to care,^{145, 166} availability of services during the pandemic,^{142, 167} convenience and cost savings associated with accessing care,¹⁶⁶ and easier access to general practice services.¹⁶⁷

There were no surveys that reported patient perspectives on the advantages of telehealth.

We have moderate confidence that patients perceive that telehealth improves access to care, services, and convenience. Our confidence was lower primarily owing to limited details on methodology and descriptions of findings and heterogeneity of the populations studied (Appendix C, Results C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.1.10. Appropriateness of Fit

We identified seven qualitative studies addressing appropriateness of fit (i.e., whether telehealth is a good fit for end users based on abilities and understanding). While some patients noted a preference for in-person visits in general,^{141, 162} they also acknowledged the need for telehealth during the pandemic. Staying at home was the primary reason that telehealth was cited as a good fit, including preferring the comfort and convenience of home,^{168, 169} the care and home-life balance,^{168, 170} and relief of financial stress owing to travel.¹⁶⁸ One study noted that patients reported an ease of effectively communicating their concerns with their providers during phone appointments; they did not perceive any decrease in quality of care.¹⁴¹ There were situations where patients felt that telehealth was not a good fit, including first appointments, appointments for new symptoms, or long-term management of chronic conditions.^{162, 171} Patients described not feeling comfortable using tele-mental health, not being able to connect to their provider, feeling that there was a decrease in the number of sessions, and that the phone was less effective.^{158, 169}

There were no surveys that collected data on appropriateness of fit.

We have moderate confidence in the varying opinions patients have about the appropriateness of telehealth. The seven qualitative studies provided findings both in favor of and against the use of telehealth for their specific concerns. The primary methodological concerns of these studies were insufficient detail about how the data were collected or analyzed. (Appendix C, Results C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.1.11. Changes to Practice

One study, conducted later in the COVID-19 era, addressed changes to practice as a facilitator to care. This study concerned people with opioid/substance use disorder and identified new procedures that limited patient exposure to others while providing the same level of service, including reduced requirements for in-person treatment, increased doses of medication to take home, and medication delivery systems.¹⁷² This was a new theme identified during the update for our review; we did not include surveys for the update.

We have low confidence that telehealth can lead to changes in practice that facilitate care. One small study of 37 individuals with opioid use disorder discussed changes in care. This study did not describe aims, recruitment, or data analysis sufficiently (Appendix C, Results C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.1.12. Future of Telehealth

Information was also gathered regarding the future of telehealth in three qualitative studies. Obstetric patients were not interested in the continuation of telehealth.¹⁷³ Patients receiving mental health noted that telehealth was convenient, but they were not interested in using it in the future.^{174, 175} This was a new theme identified during the update for our review; we did not include surveys for the update.

We have moderate confidence that patients do not consider telehealth in the future as a good option. The three included studies had minor methodologic concerns but, most importantly, only gathered information from patients receiving care for mental health or obstetrics, which may have biased opinions (Appendix C, Results C.4; Appendix D, Evidence Table D.22; Table 17).

3.4.2.2.1. Telehealth Literacy

Eight qualitative studies discussed issues of telehealth literacy from the provider perspective. Four studies noted telehealth literacy as a barrier to using the telehealth platform that included connectivity issues,¹⁸⁹ the initial setup of the telehealth platform,¹⁹⁰ and patient knowledge.^{189, 191, 192} Providers across five studies noted various barriers in patients using telehealth, the most common of which were issues related to patient knowledge¹⁹² and digital literacy levels,^{189, 193} especially among specific geographic, aging, and racial/ethnic groups.¹⁹⁴ Mitigating digital literacy barriers was noted as a concern.¹⁹⁵ Suggested facilitators to implementing telehealth services were noted by providers in three studies and included online or paper modules for using and interacting with the telehealth platform,¹⁹⁰ online modules that are specifically targeted to support staff,¹⁹⁰ more training and time dedicated to learning to use telehealth,¹⁹⁶ and calls made ahead of telehealth appointments to help patients navigate inside the portal.¹⁸⁹

Six surveys^{190, 193, 196–199} identified telehealth literacy as a barrier, with providers citing concern about patients’ ability to use telehealth^{193, 196, 197, 199} and concerns about their own ability or time to learn new systems.¹⁹⁰ Three surveys identified telehealth literacy as a facilitator,^{197, 200, 201} with providers identifying their own telehealth ability as good to very good and noting their comfort using telehealth. The survey data are similar to the qualitative data in that the populations are predominantly based in the United States and the telehealth was primarily delivered via video. However, healthcare system data are lacking in both types of study and practice type/or specialty, and the timing of the studies was heterogeneous in both the qualitative and quantitative studies (Appendix C, Results Table C.5).

We have moderate confidence that providers find the telehealth literacy of their patients to be a barrier to care and that their own telehealth literacy can be increased through training. Our concerns with the studies were lack of transparency in data collection and limited presentations of findings. Additionally, there is overall heterogeneity of the populations studied (Appendix C, Results Table C.6; Appendix D, Evidence Table D.22; Table 18). Surveys identified additional barriers for patients from the provider perspective; however, surveys reported that providers were confident in their own telehealth literacy.

3.4.2.2.2. Cost

Nineteen qualitative studies elicited provider feedback about costs associated with telehealth. While providers found the telehealth model desirable and sustainable, the most consistently noted barrier was financial limitations related to charges for service delivery or reimbursements and revenue.^{190, 192, 202–206} Conversely, some providers described the financial impact of converting to telehealth as minimal²⁰⁷ with an added benefit of reducing the financial burden to patients experiencing health disparities.^208–211 In addition, providers expressed concern that telehealth might be overused in the future as a cost- and time-saving measure, even if not in the best interest of patients.^{212, 213}

Concerns about the time and work involved with checking each patient’s medical coverage were noted,¹⁸⁹ as was the inability to conduct physical assessments.¹⁸⁹ Opioid treatment programs in one study offered telehealth services either for medication management and/or psychosocial services only.²⁰² Results from two studies questioned whether the telehealth model is sustainable.^{214, 215} A suggested facilitator was to designate one person to validate coverage/billings costs for certain visits (e.g., nutrition telehealth visits).¹⁸⁹ Providers expressed a need for organizations to provide financial assistance in order to obtain adequate technologies necessary for successfully implementing telehealth services.^{210, 216} They also expressed concerns about the costs associated with staff workload pressures and lack of human connection for patients.²¹⁷

Table 18

Summary of the evidence for provider perspectives of barriers and facilitators (N=60).

Six surveys identified cost as a barrier to telehealth,^{245, 279–282} with healthcare providers concerned about reimbursement^{245, 281, 282} and the general increase in the cost of business.^{279, 280} Two surveys reported benefits of telehealth in relation to cost: reduced travel burden²⁸³ and the ability to deliver care at the same cost via telehealth.²⁸⁴ Qualitative data were collected more often in the United States than surveys and more frequently included video as a mode of delivery. There were no common findings across the two types of studies in reference to healthcare system, clinical specialty, or time period that the data were collected (Appendix C, Results C.5).

We have moderate confidence that the cost of telehealth can be a barrier to care owing to limits to insurance reimbursement. Our confidence was lowered owing to concerns about insufficient details about recruitment and data collection. Three studies included a moderately detailed discussion of costs as a barrier; most of the studies that discussed cost as a possible facilitator included moderately detailed discussions. Additionally, there was overall heterogeneity of the populations studied (Appendix C, Results Table C.6; Appendix D, Evidence Table D.22; Table 18). The surveys echoed the concern about reimbursement, but providers also noted in the surveys that telehealth could reduce costs by reducing their travel burden.

3.4.2.2.3. Privacy

Ten qualitative studies described providers’ concerns about privacy in telehealth. Privacy concerns were related to maintaining confidentiality in the digital environment,²¹⁹ especially if patients accessed telehealth in public places.²¹⁸ Some providers noted that a benefit of telehealth was increased privacy, which supported greater comfort for patient disclosure and help-seeking,^{171, 220} while others cited difficulties ensuring privacy and confidentiality.^221–224 Difficulties ensuring privacy stemmed from patients having children and/or other housemates that made it difficult for them to express themselves freely, as they did not want their conversation overheard or had to work around the schedules of other people in the household.^{223, 224} In addition, inadequate privacy may limit the accessibility of remotely delivered services.^{225, 226}

There were no surveys that collected data on privacy from a provider perspective.

We have moderate confidence that there are issues related to privacy in the context of confidentiality from a provider perspective. We had concerns related to transparency of data collection, recruitment, study design, and analysis in the two qualitative studies. We also have moderate confidence that privacy is a facilitator to telehealth. We had concerns about data collection, recruitment, and analysis, however, findings related to privacy were thoroughly described (Appendix C, Results C.6; Appendix D, Evidence Table D.22; Table 18).

3.4.2.2.4. Health Outcomes

Thirty-three qualitative studies discussed health outcomes associated with telehealth from the provider perspective. Providers in one study noted a preference for phone over video as lockdown eased, even though they were able to achieve physical assessments (e.g., gait and respiratory monitoring) via video.²⁴³ Providers’ most frequently cited limitation of telehealth was the lack of physical interaction/exam with patients.^{143, 192, 231, 239, 240, 244} Providers also noted concerns with telehealth appointments: less information to inform clinical decision-making,²⁴⁸ inadequate quality of care provided via the telehealth environment versus face-to-face,²⁴¹ potential risks to patients and providers from virtual interactions,²³⁴ concerns about prescribing certain medications,²⁴⁷ the continuity of the rehab process and developing rapport,^{233, 240} and potential for patients to become distracted in the home environment.²⁴⁴ Providers noted telehealth as resulting in a lack of physical contact,¹⁴³ being more exhausting than face-to-face therapy,²³⁷ and resulting in feelings of loneliness, all affecting therapists’ well-being at work.²³⁷ In addition, providers noted difficulties in providing a standard level of patient care, resulting from poor quality of technology; however, they also felt that the technology facilitated unexpected positive outcomes, such as being able to meet families and providing innovations for group therapy.²²⁹ Providers discussed a potential drop in their productivity.¹⁹⁸

Improved outcomes associated with telehealth noted by providers were a more holistic view of the patient and their home environment,²⁵⁰ more opportunity for families/caregivers to be involved in telehealth visits,^{182, 231, 236} facilitated clinical assessment and treatment,¹⁹¹ patients being able to set up a relaxing experience in their home,¹⁸² improved client contact,²³¹ and maintained or improved quality of care.²¹⁸ In addition, video visits were described as advantageous, as they were convenient and saved patients time and money, particularly for older patients and those traveling long distances for in-person appointments.^{182, 245}

Providing and facilitating access to video visits to all patients was reported as an important goal, which might be accomplished by engaging and empowering health system personnel to expand access.¹⁹⁵ This action would help to streamline scheduling processes and video visit workflows¹⁹⁶ and provide clinic staff support to prepare patients for visits.¹⁹⁶ To be sustainable, “Patients’ suitability for video visits would need to be determined during scheduling based on several criteria (e.g., physical examination needs, patient’s technological capacity and demographics, new versus return).”²⁴⁵

Providers noted that the use of telehealth reduced travel time,^{240, 246} is more convenient,^{246, 248} and allows for time flexibility.¹⁸² Telehealth was noted as improving patient access to care^{230, 236} and facilitating continuity of care.²⁴⁵ Providers expressed that their experiences providing pain rehabilitation via telehealth were tightly linked to whether the methods could be used properly, related to technology, the environment, the patient, and the provider/care team.²²⁷ Providers expressed appreciation of continued care, facilitated through equitable patient access to required technology and devices (e.g., smart phones, tablet, e-mail).^{190, 228}

Providers felt that telehealth facilitated access to colleagues with prior telehealth experience, accessible electronic medical record (EMR) data to plan telehealth care visits in advance of visits, and assistance for office staff in telehealth scheduling and administration.¹⁹⁰ One group altered how they could use telehealth to triage or collect a medical history before an in-person visit, thereby minimizing exposure time.²³⁵ Having good technology setup²⁷⁹ and training were seen as necessary for successful implementation,^{238, 249} as were having a technology advocate²⁴² and flexibility of telehealth platforms.²³² In addition, providers felt it was important to provide technological access and support.^{196, 244}

Limited and conflicting information regarding outcomes from the provider perspective was available in the survey data. One survey of psychiatrists found that providers thought that their video sessions were equivalent to face-to-face sessions;²⁰⁰ and, in another survey of neurosurgeons, providers felt that the quality of care via telehealth was inferior to face-to-face visits.²⁸⁵ Owing to the heterogeneity of data in the qualitative studies, we cannot point to any similarities across the groups (Appendix C, Results Table C.5).

We have moderate confidence that telehealth can be a barrier to health outcomes owing to a lack of physical interaction with patients. However, providers noted that telehealth can also give a more holistic view of patients and their environment and, in that way, could improve quality of care. We have concerns about transparency and sufficiency of data collection as well as analytic procedures.

Further, telehealth access impacts provider ability to deliver care which impacts patient outcomes. There is overall heterogeneity of the populations studied (Appendix C, Results Table C.6; Appendix D, Evidence Table D.22; Table 18). Information on outcomes was only found in two surveys and is not comparable to the qualitative data; the surveys only recorded provider impressions of the equivalence of telehealth to face-to-face visits.

3.4.2.2.5. Communication

Sixteen qualitative studies detailed the provider perspective of communication in telehealth. Providers noted barriers in communication and developing rapport, which they felt was not as effective in telehealth compared with in-person visits owing to technical limitations that exacerbated the lack of visual cues, eye contact, and body language (i.e., nonverbal limitations).^{191, 198, 215, 246, 248} In discussing technical limitations, providers noted Zoom fatigue²⁵¹ and managing group dynamics,²⁵¹ in addition to concerns about delays in examination, time to complete evaluation,²⁴⁴ privacy,^{214, 250} and lack of “water cooler” opportunities to collaborate with other therapists, caregivers, or patients.²³³ Providers noted concerns about how patients regard telehealth appointments, such as the formality with which patients do/do not regard the virtual appointment (e.g., driving during the appointment).²⁵²

Provider-noted facilitators included having a centralized patient call center to facilitate patient technological troubleshooting and scheduling;¹⁹⁰ providing explicit orientation to etiquette expectations;²⁵¹ offering individual coaching, as needed, to facilitate social competency with telehealth;²⁵¹ and having good leadership and teamwork practices that support telehealth.²⁵³ Other facilitators noted by providers were to use end-of-day clinical debriefs among the care team, check-in with clients after already scheduled visits, and/or use text and phone for outreach.²⁵¹

Providers felt that telehealth resulted in increased comfort for patients in their own home²⁴⁶ and described video visits as convenient and efficient²³¹ and as facilitating better emotional connections.²⁴⁸ Of note, providers stated that telehealth resulted in their ability to use new strategies for connecting with patients,²⁴⁶ such as being able to add visual cues to aid to their discussions (e.g., during dietary conversations, holding up the actual food item).¹⁹² Findings of one study showed that telehealth services may not be appropriate for patients with complex diseases or situations that require a great variety of health services.²³⁷ Providers felt that telehealth facilitated easier connectivity to patients,²⁵⁰ in particular for teenage patients who tend to use telehealth visits more than in-person visits, offering increased insight into how patients/families manage their disorders at home.¹⁹²

Six surveys collected information on telehealth and its impact on communication.^{196, 200, 245, 250, 282, 286} In one survey, providers noted that they had good rapport and were able to connect well with their patients via telehealth.²⁰⁰ The remainder of the surveys pointed to concerns about or barriers to communication between provider and patients: providers had concerns about sharing information with other healthcare teams and understanding patient preferences for care;²⁵⁰ expressed a desire for training in reference to telehealth communication, communicating post-visit instructions, or using interpreters on calls;^{196, 245, 282} had difficulty reaching patients and recognized patient preferences for face-to-face communication.²⁸⁶ Both the qualitative studies and surveys took place primarily in the United States but are not comparable to one another across mode of delivery, healthcare system, or provider specialty (Appendix C, Results C.5).

We have moderate confidence that telehealth can both impede and facilitate communication between provider and patient: barriers include telehealth platform fatigue and provider concerns about patients’ casual approach to telehealth care; facilitators include increased patient comfort and easier connectivity to patients. Concerns about this body of evidence include a lack of transparency in data collection and analysis and descriptions of communication issues that were not thorough in over one-third of included qualitative studies. Additionally, there is overall heterogeneity of the populations studied (Appendix C, Results C.6; Appendix D, Evidence Table D.22; Table 18). Survey data identified a different set of provider concerns about and benefits of telehealth for communication.

3.4.2.2.6. Inequity

Eighteen qualitative studies addressed inequity as a concern for providers. While providers felt that telehealth improved patient access to care,^{218, 230} access was described as potentially different for some populations (e.g., rural, disabled, those without reliable internet service) raising the issue of equity in access to healthcare.^{214, 231, 240, 248, 252, 255, 257} Providers highlighted issues with patients’ ability to access the technology and/or equipment,^{192, 228, 245, 250, 256} especially for remote/rural communities^{189, 198, 241, 242, 254, 257} or for those who have limited resources, such as limited internet access or equipment.²²⁸

Eight surveys of providers collected information on telehealth inequity.^{196, 199, 245, 253, 280, 282, 286, 287} Inequity was noted as connection (Wi-Fi or internet) access or issues^{280, 287} and the potential that patients’ limited financial resources could limit access.^{196, 199, 253, 280, 282} These surveys are not comparable to the qualitative studies in terms of where studies were conducted, mode of telehealth, clinical specialty area, or timing of data collection (Appendix C, Results C.5).

We have high confidence that inequity, in the context of access to telehealth, is a concern for providers across specialty areas. We had only minor concerns regarding data collection, accuracy, transparency, and analysis (Appendix C, Results C.6; Appendix D, Evidence Table D.22; Table 18). The survey information collected aligned with the qualitative data.

3.4.2.2.7. Technical Issues

Twenty-seven qualitative studies identified technology challenges, including digital literacy, experienced by many providers and their staff. Providers noted that technical difficulties sometimes resulted in missed appointments²⁶² and that there were inadequate resources available to resolve these technical issues.^{192, 206, 255, 262, 265} Providers noted logistical challenges in accessing the telehealth technology.²⁴⁶ They also indicated that the swift transition to telehealth after March 2020, and the minimal use of it prior to that, greatly affected the ease of implementation.^{190, 215, 248} There were concerns about patients’ variable internet speeds, which could result in insufficient diagnostic ability.²⁴⁷ Providers noted difficulties accessing telehealth services in hospice care.²⁶⁰ The delivery of services through telehealth²⁶⁴ may be limited by patient, provider, and technological factors;^{230, 232, 244, 258, 259} the absence of desired functionalities, such as a virtual waiting room or a chat function, resulted in challenges in the workflow,¹⁴³ and some providers found telehealth to be time consuming.^{192, 247} In addition, providers noted a potential loss of access to the electronic medical record when working remotely.²⁴² Some providers described challenges that their opioid treatment providers faced in implementing telehealth services, citing clinic capacity.²⁰² Likewise, some providers noted the time demands and costs associated with setup.²⁴¹ Recent transitions to the electronic medical record exacerbated unfamiliarity with telehealth administration and scheduling.¹⁹⁰

Digital literacy of both patients and providers was raised as a concern by providers.²⁵⁰ Providers described limited abilities to prevent technical difficulties as a barrier.¹⁸² Such difficulties disproportionately affected older and economically disadvantaged patients who may struggle to use laptops and tablets^{261, 263} and lack digital proficiency.²⁴⁰ Technological limitations also included ease of use and the learning curve of therapists and patients;²³³ while usability was considered high, usability/technical difficulties and lack of digital literacy affected implementation and ease of use, especially with logging on and maintaining continuous Wi-Fi or data connection throughout the visit.¹⁴³

We identified 12 surveys of providers that addressed barriers to telehealth caused by technical issues.^{179, 182, 193, 196, 245, 250, 255, 280, 288–291} There was a wide variety of concerns identified in the surveys: for example, connection issues encountered prior to consultation on both the provider and patient ends,^{182, 250, 280} concerns about implementation²⁹¹ and provider training needs,¹⁹⁶ and the quality of audio/video.^{250, 290} Most data in both qualitative studies and surveys were collected from a U.S. population, and about half of the included qualitative and survey studies evaluated video visits (Appendix C, Results C.5). There were no surveys that collected data on digital literacy from a provider perspective.

We have high confidence that providers feel that technical issues can negatively impact access to care across specialty areas. We had only minor concerns regarding data collection, accuracy, transparency, and analysis. Additionally, there is overall heterogeneity of the populations studied (Appendix C, Results C.6; Appendix D, Evidence Table D.22; Table 18). Information collected via surveys support this conclusion.

3.4.2.2.8. Appropriateness of Fit

We identified five qualitative studies that assessed appropriateness of fit (i.e., whether telehealth is a good fit for end users based on abilities and understanding) of telehealth from the provider perspective. Providers described the fit of telehealth modalities (i.e., phone and video) as variable, depending on the patient.²⁰² In all, providers noted that telehealth is appropriate for some patients but not all.^{182, 196} Decisions for which patients should receive alternative consultations, telehealth versus face-to-face, were based on three main considerations: (1) minimization of risk, (2) adherence to guidelines, and (3) preference for face-to-face consultations.¹⁹¹ Providers felt that some patient groups, such as Indigenous people, simply did not like the idea of video interactions.²⁶⁴

There were no surveys that collected data on appropriateness of fit from a provider perspective.

We have high confidence that telehealth can be used appropriately, as long as alternative delivery of care is considered. We had only minor concerns regarding data collection, accuracy, transparency, and analysis (Appendix C, Results C.6; Appendix D, Evidence Table D.22; Table 18).

3.4.2.2.9. Future Use

Sixteen studies addressed the future use of telehealth services. Some providers reported a strong desire to return to in-person models, which some felt reflected best practices and facilitated peer interaction and support.²⁷² Similarly, many providers stressed the need for flexible modes of delivery based on patient suitability and patient/provider preference, citing a blended/hybrid model as the best approach in the future of care delivery.^{266, 267, 269, 271–274} Providers learned to be proactive and anticipate future challenges and difficulties and plan accordingly to reduce their negative impact.²⁷⁰ Providers suggested the need for information on adapting practice models for assessing patients via telehealth,^{223, 271} integrating EMRs,²¹⁶ and educating and better integrating patients and families/caregivers, which they felt improved over time/with exposure to telehealth.^{216, 223, 267, 268} Increasing insurance coverage for telehealth was noted as a necessary component of successful future use.^{267, 269, 274}

Some providers felt that telemedicine increased work/life balance because telemedicine allowed them greater ability to multi-task, take more breaks, and spend time with family while working from home.^{225, 273} However, physicians also noted that working from home invited more interruptions and pressed the need for clinicians to focus on telehealth sessions and manage their time.^{223, 225, 267} In addition, there were noted social concerns that included feelings of isolation and decreased informal communication with coworkers;²²⁵ providers noted higher levels of exhaustion from telemedicine sessions²⁷³ and stressed that future use is best suited in environments where there are adequate numbers of direct service providers to deliver quality telehealth.²¹⁰

Successful future implementation relies on ensuring adequate staffing and time for virtual appointments.^{272, 275} One study noted that a threat to long-term sustainability was that several new and expanded programs did not have long-term staffing plans.²⁴⁹ Also, making sure that community interventions (such as Wi-Fi enhancers and universal broadband access) and education/training were implemented to ensure improved quality of and access to telehealth visits, especially for underserved populations.^{216, 223, 267, 276} There were also concerns about the lack of legal protections for those conducting appointments via telehealth.²⁷⁴ In addition, the cost of telehealth software was perceived as a barrier to future implementation of telehealth services.²¹⁰ This was a new theme identified during the update for our review; we did not include surveys for the update.

We have high confidence that telehealth can be used in the future, as long as hybrid models are available based on patient preference and appropriateness of telehealth for certain conditions. We had minor to very minor concerns regarding data collection, accuracy, transparency, and analysis (Appendix C, Results C.6; Appendix D, Evidence Table D.22; Table 18).

3.4.2.2.10. Preparedness for Future Implementation

Three studies described preparedness for future implementation. “Preparedness” was operationalized to include both available equipment and adequate staff capacity to provide telehealth services.²⁷⁷ Clinics that already used telehealth in their practice, and had adequate resources (i.e., audio-visual technologies and instructional materials and procedures) and infrastructures to support its use, were better able to pivot to increasing telehealth use.^{277, 278} Those who were less well prepared, however, had a more difficult time. One study described attempts to mirror face-to-face appointments from each clinic setting for telehealth services to ease the transition and to ensure successful implementation.²⁷⁸ Institutional support was described as a key facilitator of telehealth implementation.²⁰⁹ The availability of equipment and the capacity of health professionals and patients to use audio-visual technologies resulted in most participants providing consultations via telephone.²⁷⁷ This was a new theme identified during the update for our review; we did not include surveys for the update.

We have moderate confidence that providers and their practices were prepared for telehealth and its future use. We had no to minor to very minor concerns related to the coherence and relevancy of our findings, and minor concerns regarding adequacy owing to the small sample size. We had moderate concerns about study methodology owing to insufficient information about data collection in all three studies, along with other minor issues (Appendix C, Results Table C.4; Appendix D, Evidence Table D.22; Table 18).

3.4.2.2.11. Changes in Practice

Seven studies described changes in practice necessary to implement telehealth in the future. Negative patient feedback prompted changes to practice models.²⁷⁰ Some regarded telehealth as a positive change¹⁷² but noted that it changed how they typically oriented patients and aligned expectations of therapy.²²³ Another study noted the need to build capacity and repurpose work roles to better integrate telehealth with in-person programs.^{217, 272, 275} To accommodate the changes and workload pressures necessitated by the virtual environment, practitioners described adaptations necessary to creating structure in their day to help mediate “Zoom fatigue” – these tactics included going for walks, taking lunch breaks, or even pretending to “go home” to help separate work from personal life.^{217, 223} In addition, providers described the need to align patients’ expectations of the telehealth environment, noting that when they were not on time, some patients left the videoconference.²⁰⁸ There were noted challenges with ensuring providers met appointment times.²⁰⁸ This was a new theme identified during the update for our review; we did not include surveys for the update.

We have high confidence that providers and their practices regard telehealth positively and that it necessitated needed changes in workflow and patient care. We had no to very minor concerns related to the coherence and relevancy of our findings, and minor concerns regarding adequacy owing to inconsistent findings. We had minor concerns about study methodology owing to insufficient information about data collection in most studies, along with other minor issues (Appendix C, Results Table C.6; Appendix D, Evidence Table D.22; Table 18).

3.4.2.3.1. Telehealth Literacy

One qualitative study of providers, patients, and caregivers recommended making telehealth platforms more amenable to older populations and those with cognitive impairments.²⁹²

Two surveys of patient/caregiver groups reported that telehealth was acceptable, they felt comfortable with the technology,²⁹³ and they experienced little to no difficulty with the telehealth platforms.²⁹⁴

3.4.2.3.2. Cost

No qualitative studies or surveys described cost from the perspective of other or mixed populations as a barrier or a facilitator to telehealth.

There were no surveys in other populations that addressed costs.

3.4.2.3.3. Privacy

No qualitative studies or surveys described privacy from the perspective of other or mixed groups as a barrier or a facilitator to telehealth.

There were no surveys in other populations that addressed privacy.

3.4.2.3.4. Health Outcomes

Five qualitative studies described health outcomes of telehealth from combined populations of patients, caregivers, and/or providers. For physical assessments via telehealth, groups reported issues with establishing continuity of care, the physical setting, focusing on available resources, the location of the care provider or child, and potential risks in the patient’s physical environment.^{233, 292} Concerns about the lack of physical exam/interaction were echoed by caregivers.²⁹⁵ Other concerns that emerged in provider and patient interviews included the logistics of the appointment²⁹⁶ and the need to confront new roles and workloads.²⁹⁷ Suggested facilitators included using a piecemeal approach to virtual care, which allowed providers to act rapidly and provided the flexibility needed for providers to select technologies based on their needs when technical challenges occurred.²⁹⁷ Another suggestion from patient/provider/caregiver perspectives was that tele-rehabilitation could be integrated as part of a hybrid delivery package, after initial visits are (ideally) home visits.²⁹²

There were no surveys in other populations that addressed health outcomes.

3.4.2.3.5. Communication

Six qualitative studies described communication from a combination of perspectives. Groups noted limitations of the virtual environment that prevent in-person evaluations, such as a physical exam or biological testing.^{244, 292, 298} Other difficulties were described as hearing difficulties, language barriers, and technical issues.²⁹⁶ Distractions in the home environment were also noted.²⁹⁸ Some patients were not able to engage during telehealth visits owing to sleeping, personal issues, or not being physically and emotionally available.²⁹⁹ Patients and caregivers expressed concerns about the maintenance of boundaries between patients and providers and between work/non-work hours.²³³

Two surveys of patient/caregiver groups reported that telehealth improved communication with their healthcare provider.^{300, 301}

3.4.2.3.6. Access

Nine qualitative studies described perspectives related to access from mixed study populations. Telehealth may be a means to improve equity/expand access, but it comes with technical difficulties.^{298, 302} One critical barrier was the “paradoxical impact” on inequities, whereby virtual technologies could improve the distribution of healthcare services for those who already have access to healthcare.²⁹⁷ Patient/caregiver interviews noted technological difficulties,^{233, 244, 303} specifically regarding ease of use and learning curves for both therapists and patients;²³³ using tele-rehabilitation would depend on assessment of a person’s physical, and digital, ability.²⁹² The telephone was seen as an effective method for obtaining a clinical history, but video appointments were necessary for examination of wounds; the overall preference was for an in-person evaluation.³⁰⁴ Review of patient medical records also highlighted technical difficulties accessing services, including ‘‘technicality,’’ ‘‘engagement,’’ and ‘‘scheduling,’’ or not specified.²⁹⁹ The barrier of scheduling issues was echoed in patient medical records, revealing that patient/caregivers who had other scheduled or unscheduled events, sometimes forgot the appointment or had conflicts.²⁹⁹ One study from the patient/caregiver perspective highlighted challenges using the online system.³⁰⁵ Telehealth worked better for some patients if a caregiver was present to facilitate/support video calling.²⁹² Staff and patients chose the telephone as an easy and accessible platform for communicating and did not consider that there was any added benefit from having a video function.²⁰⁶

Two surveys of patient/caregiver groups reported that they had no problems accessing telehealth and, further, described telehealth as easy to use.^{301, 306}

3.4.3.1.1. Ease of Use

Five qualitative studies described satisfaction with ease of use of telehealth from the patient perspective. Patients noted the convenience of telehealth^{159, 289, 307} and felt that telehealth appointments increased appointment flow²⁸⁹ and provided better access.³⁰⁷ “A further aspect to consider when evaluating the satisfaction with telehealth in this study is that many patients were grateful to receive care during the COVID-19 pandemic and considered telehealth to be the safest and only option.”¹⁴² In addition, a mixed-model clinic structure (i.e., telehealth and face-to-face clinic provided simultaneously) was reported as ideal, as long as patients were able to see a doctor if their condition deteriorated, as well as annually/biannually for examination and ‘check[ing]-in.’¹⁴² However, one group of patients expressed concerns about the necessity of having a quiet home environment, free of distractions, or any other factors preventing them from learning or performing the self-administered tasks/treatments.¹⁵⁶

Ten surveys described satisfaction or dissatisfaction with ease of use of telehealth.^{149, 181, 184, 279, 302, 308–312} A common theme across surveys was patients noting that telehealth was convenient.^{184, 279, 308, 310} Another theme was ease of scheduling, set up, and use of the systems for healthcare.^{149, 309, 311, 312} One study reported that patients found it very difficult to set up a telehealth appointment¹⁸¹ and another cited distractions in the home environment as an impediment to use.³⁰² The survey and qualitative data were similar in that half of the included studies were U.S.-based, otherwise they were not similar in terms of mode of telehealth delivery, patient condition, or timing of the study (Appendix C, Results Table C.7).

We have moderate confidence that patients are satisfied with the ease of use of telehealth. Our confidence is limited owing to insufficient detail related to data collection and analysis and limited discussions of satisfaction in three of the five studies (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19). Information collected via surveys supports the findings that patients find telehealth easy to use.

Table 19

Summary of the evidence for patient satisfaction and dissatisfaction (N=30).

3.4.3.1.2. Access

Five qualitative studies described satisfaction with access to telehealth from the patient perspective. Patients noted telehealth as a convenient method for accessing care.^{144, 313, 330} Access to care (i.e., attendance and engagement), especially for those who might be unable to travel to appointments, was facilitated by telehealth.³³⁰ When discussing access, patients also raised concerns about ethical issues, for which patient consent to use personal data and closed/password-protected online sessions were recommended to prevent uninvited interruptions.¹⁶⁰ Suggestions for what would be helpful included simplifying the process of connecting to the virtual platform and improving Wi-Fi connectivity issues.¹⁴⁰ Additional concerns regarding appointment scheduling were discovered in studies conducted later in the COVID-19 era. Patient portals for scheduling were cited as an issue,²¹³ as well as portals for access to the clinicians: for instance, difficulty with the portal and video conferencing;^{138, 175} and administrative “gate-keeping,” where clinical support staff prevented contact with the providers.^{213, 314}

Five surveys described satisfaction with access to telehealth.^{142, 176, 179, 239, 331} Satisfaction was rated for convenience and ease of access to care^{179, 239, 331, 332} and a desire to continue to use telehealth for care.¹⁴² Study populations in the qualitative studies and surveys were not comparable except for mode of telehealth delivery; both the qualitative studies and surveys collected information primarily from patients who received telehealth via video (Appendix C, Results Table C.7).

We have moderate confidence that patients express both satisfaction and dissatisfaction with access to telehealth care. There was a lack of detail about data collection and analyses in more than half of the studies, reducing our confidence in the findings (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19). The survey data support the finding that patients were satisfied with telehealth as a convenient way to access care; there were no survey data that recorded concerns about access.

3.4.3.1.3. Health Outcomes

Eleven qualitative studies described satisfaction with health outcomes associated with telehealth from the patient perspective. Patients generally described telehealth as positively impacting patient convenience and the overall experience.¹⁴⁷ In one study, attendance was high and all parents stated that overall satisfaction with care was high; more than 90 percent of respondents reported satisfaction with telehealth consults and 100 percent reported satisfaction with treatment procedures via telehealth.³¹⁵ Other studies cited satisfaction about the relaxed atmosphere of telehealth;³¹⁶ and, in a study on exercise, the participants believed telehealth to be instrumental in their continuation of physical activity during the COVID-19 era.¹⁶³ Online integrative oncology treatment was identified by patients to have beneficial effects that included increased feelings of caring, containment, support, calm, and empowerment.¹⁵⁶

Challenges and dissatisfaction were noted in obstetrics and gynecology, specifically regarding pregnancy: patients felt that their health concerns were not adequately addressed during telehealth visits, and there was an overall sentiment that telehealth was inappropriate for this population.^{165, 173}

Four surveys identified satisfaction or dissatisfaction with telehealth’s impact on health outcomes.^{179, 333–335} Patients felt safer seeing their providers remotely³³³ and noted that they believed that the telehealth visit helped with their reported complaints. Patients also noted that they felt that a face-to-face exam would have been better, citing blood pressure cuffs and Doppler imaging as examples of things that would improve their care and outcomes.^{179, 335} Qualitative data on oncology patients were collected in three studies taking place in three different countries; survey data were also collected in multiple countries, otherwise they were not similar in terms of mode of telehealth delivery, patient condition, or timing of the study (Appendix C, Results Table C.7).

We have high confidence that patients are satisfied with the health outcomes from telehealth and find that it is beneficial to their overall care and receipt of treatment procedures. Our limited concerns are owing to insufficient data provided about data collection and analysis; however, sufficient descriptions of outcomes had a strong impact on our confidence. (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19). In general, the survey data agreed with the qualitative data. However, two surveys noted that face-to-face interactions would have been better for recording blood pressure or Doppler readings and could have improved outcomes in ways telehealth could not.

3.4.3.1.4. Communication

Nine qualitative studies described satisfaction with communication associated with telehealth from the patient perspective. Patients noted being satisfied with having access to see and discuss their health concerns with a telehealth nurse, whom they appreciated being the same telehealth nurse for each visit.¹⁴⁰ This same group of patients perceived greater accessibility in scheduling visits.¹⁴⁰ Other patient groups responded that the telehealth platform facilitated building and maintaining relationships between family and healthcare providers,³¹⁸ resulting in retained independence and social connectedness throughout the COVID-19 pandemic,³¹⁹ as well as maintaining ongoing treatment discussions when patients were not able to go to the office in person.¹⁵⁶ Some patients felt that telehealth was comparable to in-patient visits and that appointments were less rushed.¹⁴⁴ In addition, being at home provided an added layer of comfort and safety,^{144, 336} and the platform allowed them to ask more questions.¹⁴⁴ Patients with specific healthcare needs (e.g., prostate check, intrauterine device removal) required in-person examination and care, resulting in increased peace-of-mind and confidence.¹⁵⁹ Among a group of patients completing group teletherapy, participants preferred to have at least one in-person meeting to meet other patients and build relationships.³²² Patients were generally understanding of the limitations resulting from the COVID-19 pandemic and the necessity to transition to an online platform, which they felt facilitated building and maintaining relationships/rapport.¹⁶⁰

Several challenges in communicating via telehealth platforms were noted in three studies. Patients noted difficulties with masks and telehealth,³¹⁵ difficulty hearing one another properly,¹⁶⁰ and challenges with scheduling followups and other future appointments.³¹⁵

To support and enhance communication, patients suggested user-centered technical features that included interactivity, were visually instructive and informative, and allowed connectivity through messaging.³²¹ Other recommendations included using secure e-mail and video methods that facilitate remote connectivity and communication.¹⁵²

More surveys than qualitative studies collected data on satisfaction and dissatisfaction with communication (N=19)^{140, 142, 148, 149, 181, 184, 185, 239, 279, 304, 309, 312, 315, 329, 334, 337–340}. Overall, patients expressed satisfaction with provider/staff understanding of patient concerns,^{148, 181, 184, 239, 337, 338, 340–342} and they also felt their needs were being met in the telehealth exams.^{148, 181, 184, 343} Patients also noted that telehealth did not negatively impact their satisfaction with treatment explanation^{149, 181, 312, 315, 334} or overall experience.^{140, 185, 339} Although, in general, patients noted satisfaction with telehealth and did not note much difference between telehealth and in-person visits,^{142, 304, 329} one study found the opposite position among surveyed patients.¹⁴² Most of the surveys were conducted early in the era of COVID-19, whereas qualitative data were collected more commonly during the general period of COVID-19. Both qualitative studies and surveys were conducted in multiple countries, otherwise they were not similar in terms of mode of telehealth delivery, patient condition, or timing of the study (Appendix C, Results Table C.7).

We have moderate confidence that patients are satisfied with telehealth and its impacts on communication. Our concerns are owing to the lack of sufficiency of detail across studies regarding data collection and analyses. We are also concerned about the sufficiency of discussion about communication as it applies to telehealth (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19). The survey data support the findings of the qualitative studies in reference to satisfaction. While the qualitative studies found some dissatisfaction with communication via telehealth, a single survey noted that telehealth limited patient communication with their providers.

3.4.3.1.5. Privacy

Eight qualitative studies addressed patient satisfaction with privacy in telehealth. Two studies found that patients were satisfied with telehealth and privacy; one study of adolescents³⁴⁴ demonstrated that patients 13 years and older liked the ability to access their patient portals, and another of adults¹⁶³ taking online exercise courses were less self-conscious in their groups. Two studies were neutral about any privacy issues that may exist during telehealth.^{169, 325} Five studies noted general dissatisfaction with telehealth privacy: patients perceived telephone counseling as more impersonal compared with in-person evaluations and noted inadequate privacy in the home environment to receive counseling services.³³⁶ Three studies gathered information pointing to lack of safety and privacy in the home environment.^{138, 174, 323} Finally, one study noted concerns about telehealth and privacy of information about self-harm and suicide.³²⁴

Three surveys addressed privacy as a measure of satisfaction among patients.^{142, 340, 345} Across these three surveys, patients noted that they felt that their privacy was protected during telehealth consultations. These surveys and qualitative studies are not comparable: the qualitative study took place in the United States via telephone-only administration of telehealth in an opioid treatment population later in the COVID-19 era, whereas the surveys were conducted in multiple countries with mixed modes of telehealth delivery (Appendix C, Results Table C.7).

We have high confidence that patients express both dissatisfaction and satisfaction related to privacy and telehealth. We had only minor concerns with the evidence owing to the lack of sufficiency of detail across studies regarding data collection and analyses (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19). The survey data do not support the finding that patients are dissatisfied or concerned about privacy issues with telehealth.

3.4.3.1.6. Benefits

Thirteen qualitative studies described patient-perceived benefits of telehealth. Telehealth was positively received by many patients,^{155, 315} especially as it provided a safe and contact-free alternative throughout the COVID-19 pandemic,³⁰⁷ which enabled continuity of care.^{145, 152, 159, 326, 327} Although some patients were skeptical of the quality of telehealth visits, especially for evaluations requiring physical assessment (e.g., eye exams), others were very satisfied and felt that the telehealth appointment was just as good as in-person, with the added benefits of convenience and ease of use.^{152, 166, 313} Telehealth was perceived to facilitate increased levels of communication, which translated into personalized care and positive health impacts.¹⁴⁵ Patients also reported benefits of telehealth that included reduced hassle, time, and costs associated with traveling to appointments.³²⁶ Other patients described a positive experience associated with telehealth¹⁵⁴ and telephone consultations,¹⁵⁰ rating the experience as good as in-person care, especially in regards to communication, building rapport, and sharing information.^{145, 150} Patients reported being satisfied and having their needs met, stating they would likely choose telehealth over an in-person visit.¹⁴⁴

There were no surveys that collected data about telehealth in the context of patient satisfaction as a benefit.

We have moderate confidence that patients are satisfied with telehealth and express their satisfaction by describing benefits. Our concerns are owing to a lack of information related to data collection and analyses. Further, discussions about the benefits of telehealth were only moderately described (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19).

3.4.3.1.7. Preferences

Ten qualitative studies described patients’ preferences regarding telehealth. Although patients described similarities between telehealth and in-person appointments,²⁸⁹ the preference was for face-to-face, in-person appointments.^{152, 166, 289} Patients felt that in-person evaluation facilitated easier conversations with providers, enhancing rapport.¹⁵² In addition, preferences for telehealth versus in-person evaluations were typically based on the health issues patients were presenting with (including severity of symptoms, likelihood of needing a physical exam, and whether they felt that they could explain themselves more clearly in-person),^{159, 307} in addition to the benefits provided by a virtual appointment (e.g., convenience and efficiency).¹⁵² This was especially true for patients who thought telehealth appointments were the best environment for discussing personal health problems.³⁰⁷ Video consultations were seen as more acceptable and were better received than telephone consultations;^{289, 307} however, the latter were preferred over video appointments in the case of a short followup appointment.¹⁴³ Patients were apprehensive about the legitimacy of telehealth³²⁸ but were grateful for the added safety in light of the COVID-19 pandemic.¹⁴⁶ In addition, patients expressed that telehealth was not well-suited for all groups, such as those who had recently undergone major surgery.³²⁹ Some felt that telehealth was acceptable after an initial, in-person evaluation³⁰⁷ and that an established relationship between patient and provider was critical.¹⁶⁶ Other patient groups felt that telehealth was especially useful for triaging patients to in-person evaluation.^{143, 166} Patients preferred telehealth appointments that were less than one hour in length, to limit the tiring effect of looking at the computer screen.¹⁴⁶ In one study, patients expressed wanting some customizable functionalities that encourage greater engagement and accountability.³²¹

There were no surveys that collected data about telehealth in the context of preferences impacting patient satisfaction.

We have high confidence that, in general, patients prefer face-to-face visits with their healthcare provider but noted that telehealth was more convenient and may be better suited for some forms of care. We had minor concerns about data collection and analyses, but descriptions of preferences were thorough across the included studies (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19).

3.4.3.1.8. Concerns

Five qualitative studies described patients’ concerns about telehealth. Patients described the challenges in conducting a telehealth appointment in view of complex care needs;¹³⁷ some had anxiety and skepticism regarding telehealth and setup¹⁶⁶ and others stated a reduced confidence in providers.¹³⁷ There were some sentiments that telehealth appointments were less personal than in-person appointments with physical exams.³⁰⁷ Patients sometimes found communication challenging, reporting difficulties hearing and challenges with followups and scheduling future appointments.³¹⁵ In addition, the use of telehealth was less common when obtaining specialist care, which often required in-person evaluation (e.g., dentistry).³²⁷

There were no surveys that collected data about telehealth in the context of concerns impacting patient satisfaction.

We have moderate confidence that patients have concerns about telehealth use for complex care, as well as concerns about setup and the lack of personal care via telehealth. Our concerns about methodology were primarily about limited findings applicable to satisfaction with telehealth (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19).

3.4.3.1.9. Suggestions

Four qualitative studies focused on patient suggestions or facilitators to improve telehealth. In these studies, patients suggested several facilitators for successful implementation. Patients felt that telehealth consultations required mutual trust between the patient and their provider; this was seen as easier to accomplish for preexisting relationships with the healthcare provider, suggesting that developing rapport/relationships with the care team might be challenging for new patients.¹⁵⁹ In one study, many patients reported a beneficial effect of telehealth, including a sense of caring and support, feeling empowered, and feeling that the appointment was calming. Telehealth facilitated patient self-efficacy and involvement in their own care.¹⁵⁶ One study suggested additional training and technical support be provided to patients to better facilitate their telehealth visit,¹³⁹ while another suggested that hybrid models of care be developed to better develop a therapeutic relationship and facilitate interpersonal connections.¹³⁹

There were no surveys that collected data about telehealth in the context of suggestions or facilitators impacting patient satisfaction.

We have low confidence that patients’ suggestions of trust development, developing rapport, additional technical support, and hybrid models of care are facilitators to telehealth. We have serious concerns about the detail surrounding data collection, data analysis, and presentation of findings (Appendix C, Results Table C.8; Appendix D, Evidence Table D.22; Table 19).

3.4.3.2.1. Ease of Use

Five qualitative studies described provider satisfaction regarding ease of use of telehealth. Providers indicated advantages to telehealth, including that it is more convenient,^{194, 242} provides flexibility and greater access to patients,²⁴² is more efficient in terms of time and utilization of office space,³²⁹ allows for remote work,²⁵⁵ and supports greater inclusion of caregivers.¹⁹⁴ However, this same group of providers felt that, overall, while telehealth works well for their work schedule, there is a lack of internet access in rural settings, and it is a tedious system.¹⁹⁴ To deal with the emergent nature of telehealth, providers reported leveraging existing systems, especially triage systems, to do the following: assess patient needs, communicate and support care-related decisions, ensure seamless transitions of care, and provide specialized support (e.g., bereavement and grief support services).²⁴¹

Eleven surveys described provider satisfaction or dissatisfaction with ease of use of telehealth. ^{143, 181, 190, 201, 242, 280, 286, 287, 337, 346, 347} Providers noted that telehealth was convenient and easy to use for both their practices and their patients.^{143, 190, 201, 227, 242, 286, 337, 346} While ease of use was commonly noted, some providers noted that integrating telehealth into current practice was difficult,²⁸⁶ citing difficulty in coordination and setup.^{181, 280} Some providers also had difficulty in providing care and noted that consultations were uncomfortable.^{181, 242, 287, 347} Populations across the qualitative data and survey data were not comparable (Appendix C, Results Table C.9).

We have low confidence that providers are satisfied with telehealth, find it easy to use, more convenient, efficient, and perceive that it provides better access to patients. Our confidence is limited owing to a lack of sufficient details about qualitative methodology, which resulted in an inability to assess rigor. Additionally, there was a lack of detail in descriptions regarding ease of use in three of the five studies (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20). The survey data support the qualitative data.

3.4.3.2.2. Access

Four qualitative studies described provider perspectives regarding access to telehealth. Providers noted being generally satisfied with the telehealth platform, stating that telehealth provides benefits to both staff and patients.²²⁹ Perceived benefits to patients included patients not having to travel, find parking, or sit in waiting rooms, providing a level of convenience not comparable to in-person visits.^{189, 286} Providers noted that some patients are not well served by telehealth, such as those who are more difficult to reach and engage via telehealth (e.g., patients with mental health conditions).²²⁹ Some providers reported issues, for both themselves and their patients, with insufficient technological infrastructure (particularly related to internet connections), describing a lack of sufficient support from the organization to help with software or devices used to access the technology.²³¹ In addition, providers felt that they needed a very user-friendly video call tool to ensure privacy standards are met, in addition to wanting features such as a digital white board, the ability to transfer files securely, and capacity for support group sessions.²³¹

Five surveys described provider satisfaction with access to care.^{143, 179, 340, 348, 349} Surveys gathered information about providers’ general satisfaction with access to care via telehealth,^{143, 348, 350} as well as provider impressions that patients can access and use telehealth.^{143, 179} Results from one survey identified dissatisfaction with access as it applies to cost of telehealth to providers.³⁴⁹ Populations across the qualitative data and survey data were not comparable (Appendix C, Results Table C.9).

We have moderate confidence that providers are overall satisfied with telehealth and believe it can increase access to care for patients in terms of travel and time. However, we have the same level of confidence that providers were dissatisfied with telehealth owing to poor infrastructure and difficulty accessing technology for both providers and their patients, potentially limiting long-term implementation. While findings are well described, our confidence is limited owing to inadequate details about qualitative methodology, which limited our ability to address methodologic rigor (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20). The survey data support the qualitative data.

Table 20

Summary of the evidence for provider satisfaction and dissatisfaction (N=54).

3.4.3.2.3. Health Outcomes

Fifteen qualitative studies described provider satisfaction or dissatisfaction with health outcomes of telehealth. Overall, providers described telehealth as increasing accountability,²⁴² improving treatment accuracy and effectiveness,³⁵¹ and increasing efficiency over face-to-face contact.²⁴¹ Providers felt that telehealth was especially useful in triaging patients.²⁵⁹ The virtual environment meant that patients were more likely to keep appointments,^{189, 326} which resulted in greater compliance,²⁴² increased patient comfort and safety,²⁴² improved therapeutic relationships,²⁴² and overall positive patient experiences.²⁵⁹ Providers noted that using telehealth services negates infection risk in hospital settings³⁵¹ and minimizes the risk of COVID-19 transmission.²⁸⁷ Others noted positive outcomes that included opportunities for patients to learn treatment skills for use in home settings²²⁸ and opportunities for providers to gain additional information about the patient: for instance, a registered dietician may be able to “look into” a patient’s refrigerator/pantry to understand home environment and diet.¹⁸⁹ One study reported that providers perceived that telehealth interactions resulted in increased focus on the topic, conciseness of the appointment, and an increased length of assessment; however, telehealth also resulted in less time or opportunity to manage all of the information.²⁶⁵ Providers felt more control over their schedules and a slowed pace, resulting in more peaceful and relaxing interactions with patients.²¹⁴

When discussing negative outcomes associated with telehealth, providers described challenges delivering treatment protocols via telehealth,²²⁸ including a lack of physical exam,^{236, 259} which complicated their ability to diagnose and treat certain conditions.²³⁶ This negatively impacted both the quality^{202, 254} and continuity of care²⁴⁵ and represented reduced accountability.²⁴² One example of this was unsupervised exercise and incorrect technique.²⁷⁹

Twelve surveys identified satisfaction or dissatisfaction with telehealth’s impact on health outcomes.^{179, 181, 219, 230, 242, 283, 284, 286, 304, 348, 355, 358} Providers noted that telehealth added value to treatment, in general,^{286, 304} and particularly during couple’s therapy.³⁵⁵ Further, providers expressed confidence that diagnoses were accurate, client concerns were addressed, and equality of telehealth were equivalent to in-person care.^{181, 242, 358} Contrary to those perceptions, some providers noted that they felt examinations suffered from lack of physical contact and the possibility to miss signs/indications of illness.^{179, 242, 284, 348} Providers did not notice a lower frequency of no-shows to therapy appointments,²³⁰ and did not observe positive patient outcomes compared with face-to-face care.^{219, 283} Populations across the qualitative studies and surveys were not comparable (Appendix C, Results Table C.9).

We have moderate confidence that providers were both satisfied and dissatisfied with telehealth’s impact on patient outcomes. Providers provided conflicting thoughts about accountability and treatment accuracy. Our confidence is limited owing to a lack of details about qualitative methodology, along with inadequate detail about outcomes in four of the 15 included studies (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20). The survey data support the qualitative data.

3.4.3.2.4. Communication

Twenty qualitative studies described communication via telehealth from the provider perspective. Some providers felt that telehealth facilitated conversations with and increased engagement of patients.^{214, 230, 242, 279} While providers agreed that clear, concise, and definitive communication was instrumental to efficient care and maintaining morale (of both staff and patients), the evolving nature of the COVID-19 pandemic made such definitive communication challenging.²⁵⁷ Providers perceived telephone conversations as more “business like,” enabling greater ability to run their clinic.²⁵⁹ Providers also discussed feeling more comfortable refusing patient requests during telehealth visits²³⁶ and sometimes used apps to draw attention to important aspects related to disease or treatment.²⁸⁶

Conducting services via telehealth, especially for those providing mental health services, made building rapport with patients more difficult,^{214, 219, 231, 242, 255, 259} which reduced the patient experience and resulted in an impersonal experience.²⁴² Telehealth may be challenging for long, in-depth sessions²⁵⁵ for new patients or those who require a more thorough exam.^{202, 259} Providers noted the lack of personal connection and touch,²³⁶ the inability to fully assess patient status²⁰² and provide a hands-on physical examination,²⁴⁵ and communication difficulties owing to sensory impairment, inadequate equipment, and uneven connectivity (e.g., in rural communities).²⁶² Further, providers noted the inability of the virtual environment to fully support nonverbal communication^{231, 259, 326} or to convey visual cues (especially when using the telephone);²⁶⁴ providers also reported needing to use visual aids.²⁴⁵ These factors were associated with difficulties in providing emotional support for sensitive topics²⁶⁵ and sometimes resulted in providers having to reassure patients that the standard of care would be maintained.³⁵²

To facilitate outreach and assessment, providers described needing to proactively assess high-risk patients, screen for social determinants of health, keep up-to-date records, and consent patients to telehealth early or on admission.³⁵² Further, providers felt that linking primary and secondary care could ease transitions of care.³⁵³ Providers suggested a timely in-person followup visit²⁴⁵ and efforts to build connectedness to counter less frequent in-person connections.³⁵² Other issues noted by providers were poor availability of patients by telephone²⁸⁶ and legal issues, such as the indemnification between the patient and provider, potentially resulting from their virtual interaction.²³⁴ Despite these challenges, once adapted, some providers described being able to spend longer times with each patient and being able to connect well with them.²¹⁴

Twelve surveys identified satisfaction or dissatisfaction with the effect of telehealth on communication.^{181, 198, 201, 219, 242, 284, 288, 333, 362–365} Providers expressed general satisfaction with telehealth as it influences communication.^362–365 They noted that telehealth was equivalent to in-person care when establishing rapport and engagement with patients,^{363, 365} and they noted that patients were able to express themselves and understand their conditions during telehealth.^{201, 284, 363} They also noted that their communication was effective^{181, 219} and that their relationship with patients improved.²⁴² Other groups of providers noted the opposite: video counseling was an impediment to communication and patient engagement.^{198, 219, 288, 364} Populations across the qualitative data and survey data were not comparable (Appendix C, Results Table C.9).

We have moderate confidence that providers are dissatisfied with telehealth: it can impede provider/patient communication owing to the impersonal nature. Findings regarding communication are well described, however, our confidence is limited owing to poor reporting of methods, which limited our evaluation of rigor (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20). The survey data are partially in agreement with the qualitative studies. While the qualitative studies point to telehealth as an impediment to communication, providers responding to surveys indicated that patients expressed themselves more freely and that telehealth was equivalent to in-person care in establishing rapport. Some surveys agreed with the qualitative studies in that telehealth was noted as an impediment to communication.

3.4.3.2.5. Benefits

Twenty-four qualitative studies focused on the benefits of telehealth from the provider perspective. Although some providers viewed in-person assessment as superior, telehealth was found to be beneficial and to increase accessibility during the time of limited in-person engagement.^{255, 258} Providers viewed telehealth as a sufficient alternative to in-person evaluation that resulted in risk reduction for patients and providers,^{238, 243, 253, 255, 257} shorter consultation lengths, and narrower gaps between need and demand (although there were concerns about access to services).²⁸⁷ Telehealth was seen as a tool to limit followup interruptions^{259, 354} and to ensure continuity of care and limit COVID-19 exposure.^{194, 203, 215, 354} Telehealth was viewed as inappropriate for new patients.²⁵⁹ Providers in one study noted an increase in remote healthcare delivery and acceptance since the start of the COVID-19 pandemic that they thought was facilitated by the availability of payments, the restructuring of policies to allow telehealth services, and the inclusion of remote consultations in appointment systems.²⁵³

Providers noted numerous benefits associated with video visits, including improvements to efficiency, capacity, and collaboration.²³² With the added value of video to observe visual cues and assess physical status,^{143, 238, 259} clinical staff members were able to continue to see a full caseload of outpatients during pandemic quarantine.¹⁸⁹ Telehealth appointments were particularly useful to see followup and post-operative patients and to more accurately triage and consult new referrals.²³⁹ Telehealth resulted in improved efficiency,^{232, 259} although not for all patient populations, such as patients requiring in-person assessment.^{230, 354} Noted benefits included continuation of services, increased availability, increased caregiver involvement, comfort of being at home, safety from COVID-19 exposure, increased flexibility, decreased travel time, preferred modality for some patients, and the integration of technology.²⁵⁸ Other noted benefits included more frequent use of telephone consultations,²⁸⁶ increased ability to collaborate,²¹⁴ and convenience of and increased access to medical and counseling services.²⁶³ Also noted were increased ability to schedule appointments, the ability of patients to do more at home, and reduced barriers to telehealth use and care.³⁵⁷ Primary care visits conducted via telehealth visits tended to be shorter than in-person visits.²³⁶ Providers felt telehealth provided comparable care while preventing unnecessary travel, in addition to providing increased flexibility and convenience and enhanced connection.²⁸⁶ Providers in one study noted that the home environment promoted stronger therapeutic rapport and connections.³⁵⁵ Providers reported feeling favorably about the ability to work from home, which saved commuting time, increased capacity to see patients more efficiently, and facilitated issues related to childcare.³⁵⁶

There were no surveys that collected data about the satisfaction with benefits of telehealth from the perspective of the provider.

We have moderate confidence that providers are satisfied with telehealth and find it beneficial to patients and providers because it improves efficiency, capacity, and collaboration. Findings regarding benefits are well described; however, our confidence is limited owing to poor reporting of methods, which limited our evaluation of rigor (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20).

3.4.3.2.6. Preferences

Sixteen qualitative studies described provider preferences regarding telehealth. There was some preference for in-person assessments;^{255, 358} providers noted being generally satisfied with telehealth^{196, 255, 259} and perceived that patients found telehealth acceptable,^{202, 215} especially once they became familiar with the process.^{156, 218, 357} Providers felt that many components of in-person visits could be accomplished successfully via telehealth, including pain rehabilitation,²²⁷ and that telehealth was especially suitable for patients with less complex care needs.²⁵⁵ Telephone consultations were perceived as suitable for most patients;²⁴³ the telephone was seen as a primary alternative to video, either because it assuaged concerns about technical challenges with video consultations or because the general practitioner already saw most of their patients face-to-face.¹⁹¹ Providers did not feel there was any added benefit from having a video function.²⁰⁶ Other providers felt that telehealth should be a permanent option²³⁰ that could be integrated as a possible complement to in-person visits, reducing patient burden (e.g., travel time).³⁵⁴ As the pandemic waned, preferences for in-person visits replaced some of the initial appeal for telehealth appointments: “There was a strong feeling from respondents that they needed to catch up on concerns that patients had put on hold because they wanted to discuss them in person.”²⁰³

There were no surveys that collected data about telehealth in the context of preferences impacting provider satisfaction.

We have low confidence that providers are generally satisfied with telehealth and believe it can replace many aspects of in-person care. Providers noted that, over time, they needed to catch up on care put on hold during the pandemic. Our confidence is limited owing to a lack of details about qualitative methodology, along with inadequate detail about outcomes in 10 of the 16 included studies (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20).

3.4.3.2.7. Concerns

Seventeen qualitative studies discussed concerns with telehealth from the provider perspective. Overall, providers noted that, while telehealth was a good alternative, it should not replace in-person, face-to-face visits;^{219, 245, 258, 286, 357} they regarded telehealth as preventing a proper physical examination, necessary especially during initial medical evaluations and ongoing treatment phases.^{227, 259} In addition, providers felt that telehealth appointments are not well suited for all types of care, noting difficulty moving in-person appointments to patients’ homes.^{156, 359} While providers were generally dissatisfied with limited face-to-face, in-person contact,^{262, 279} video consultations were seen as “better than nothing.”³⁶⁰ Some providers felt that this choice depends on personal preference³⁵⁷ and expressed concerns about working remotely from their personal space.^{279, 357} Others felt that remotely-delivered care resulted in patients relying more heavily on them during off-hours.³⁵⁶ While many issues negatively impacted sustainability of the telehealth model, two primary issues stood out: not being able to conduct a physical exam and technical difficulties.^{238, 245, 258} Providers’ acceptance of video visits was similarly challenged by the technology and impact to workflow efficiency and communication.^{241, 245, 258} Providers were concerned about the sufficiency of telehealth in providing a long-term, successful outcome.²²⁷ They worried that patients who are critically ill and need to be seen in-person might fall through the cracks or be scheduled inappropriately for telehealth appointments.²¹⁴ One way providers dealt with this was to request more investigations to clarify questions not answered in the virtual environment owing to the lack of physical examination.²⁵⁹ Some providers felt that more attention needed to be paid to understand relational processes in effectively communicating with patients via telehealth modalities.²⁴² Many decision moments were present, however there was insufficient information available.²⁸⁶

There were no surveys that collected data about telehealth in the context of concerns impacting provider satisfaction.

We have high confidence that providers had some concerns leading to dissatisfaction of telehealth and felt that it should not replace face-to-face visits, as telehealth precludes physical exams and is not suited for all types of care. Findings regarding benefits are well described across all studies with a small percentage with poor reporting of methods, which limited our evaluation of rigor (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20).

3.4.3.2.8. Provider Suggestions

Eleven qualitative studies discussed provider suggestions for implementing telehealth services from the provider perspective. Providers felt that future use of telehealth should be considered in combination with traditional, in-person visits²⁸⁶ to ensure regular and appropriate followup, especially for particular patient populations (e.g., those who live far away from in-person care).³⁵¹ Providers discussed the importance of stimulating the use of eHealth services to ensure successful and wide-spread implementation.³⁵⁷ Providers suggested that organizational readiness, engagement, and leadership are critical for successful telehealth implementation.³⁶¹ Several factors to assess readiness to change and support the implementation of telehealth were suggested: (1) measuring awareness and acceptability among target groups; (2) providing safe, private, comfortable, and context-sensitive environments for patients; and (3) providing sufficient care across modalities.³⁵⁷

At the system level, facilitators to the implementation of telehealth included governmental or organizational supports, such as health reforms or strategies that facilitate the increased acceptance of telehealth services.²⁵³ At the organizational level, providers felt their ability to provide remote services was further enhanced by training and continuing education to achieve acuity in providing services via telehealth.^{219, 353} In addition, access to formal and informal inter-organizational networks and recognition of external policies and protocols were highlighted.³⁶¹ Further, providing clinic staff with access to knowledge and information were seen as critical components to promoting provider and staff self-efficacy,³⁶¹ and one study highlighted the need for careful consideration of providers’ workflows to avoid work overload and burnout.²³⁶ Regarding the latter, “It became easier when they found ways to introduce clients to the therapeutic frame, send intake forms via e-mail, and speak with their clients about the challenges that come with remote treatment.”²¹⁹ Increased resolution of video images facilitated remote physical assessments.²³⁹ To mediate some of these issues, providers suggested: “(1) screen sharing to facilitate patient education and explain imaging results, (2) a waiting room function to replicate “stepping out of the room” when engaging with trainees, (3) a chat box for troubleshooting, (4) file sharing capabilities, (5) screenshot capabilities to support efficient charting, and (6) multi-person teleconferencing to include other members of the multidisciplinary team, interpreters, trainees, and family members in different physical locations.”²⁴⁵ Some providers noted that telehealth is here to stay and can no longer be ignored.²⁵⁷ To facilitate its sustainability, remote delivery of care was seen as needing equal payment structures and technological support.²⁸⁶ Social workers in one group noted that access to technology and other necessary supports facilitated their ability to complete their work, whether remotely or on-site via telehealth.²⁵⁷

There were no surveys that collected data about telehealth in the context of suggestions or facilitators impacting provider satisfaction.

We have moderate confidence that providers are satisfied with telehealth but suggested that telehealth in combination with in-person care should be considered for the future. Our confidence is limited owing to a lack of details about qualitative methodology, along with inadequate detail about outcomes in four of the 11 included studies (Appendix C, Results Table C.10; Appendix D, Evidence Table D.22; Table 20)

3.4.3.3.1. Ease of Use

One qualitative study of providers and hospital administrators noted that telehealth improved ease of completing visits.³⁰²

Two surveys of patients and their caregivers addressed ease of use. In one survey the respondents noted that the telehealth equipment worked well and it was easy to speak with the provider,³⁶⁶ and another survey noted some dissatisfaction of the patients and caregivers regarding the instructions for using telehealth.²⁹⁴

3.4.3.3.2. Access

Four qualitative studies of combined populations discussed telehealth access. One caregiver group noted being satisfied with not having to travel to appointments,²⁹⁵ and a group of patient and caregiver respondents noted the convenience of being able to complete testing at home.²⁴⁴ Patients and providers described reduced patient travel time and increased access owing to the ease of scheduling and accessing appointments.²⁹⁸ In another study, nurses and aides identified scenarios such as evaluating poor wound healing, signs and symptoms of infection, weight gain, and respiratory difficulties as issues for which telehealth (via video) would be especially useful.³⁶⁷ In this same study, patients and caregivers cited rashes, incisions, wounds, bleeding, and sore throat as issues for which the platform would be especially useful.³⁶⁷

Two surveys of patients and their caregivers identified positive aspects of access: one study noted that the respondents liked that the challenges of getting to their appointments were eliminated;²⁹⁵ another study noted the following benefits: no time away from work, no travel, and saved time.³⁰⁶

3.4.3.3.3. Health Outcomes

One study with both patients and hospital administrators concluded that telehealth improved patient comfort.³⁰²

There were no surveys that collected data about telehealth from other user groups in the context of impact on outcomes.

3.4.3.3.4. Communication

Four qualitative studies reported data regarding communication from combined populations. In a group of patient and hospital administrators, the majority of respondents felt that telehealth resulted in diminished human connection and rapport, resulting in part from an inability to read non-verbal communication.³⁰² Patients and caregivers in one study noted telehealth as being subpar compared with in-person services, so telehealth was, therefore, not seen as a long-term solution or substitute for pre-COVID-19 era levels of care.³⁶⁸ One caregiver group described being able to receive a good level of care and compassion, even via telephone.³⁶⁹ Another patient/caregiver group provided generally negative feedback, citing technical difficulties (e.g., issues getting connected to the platform, losing internet connectivity), as well as limitations of evaluation within the virtual appointment.²⁴⁴ In most cases, staff and patients chose the telephone as an easy and accessible platform for communicating and did not consider that there was any added benefit from having a video function.²⁰⁶

Three surveys of patients and their caregivers addressed improved communication via telehealth. These groups noted that they were more comfortable about discussing their emotional health via telehealth,³⁷⁰ and they had the impression that providers were caring during the telehealth visit.³⁷¹ Another survey identified overall satisfaction with/ease of communication via telehealth.³⁰¹

3.4.3.3.5. Benefits

In general, users felt satisfied with their telehealth visit in terms of benefits.^{244, 304} Both patient/hospital administration groups,³⁰² as well as patient/caregiver groups,³⁰⁵ noted the overall acceptability of telehealth and felt that it was especially adaptable to the COVID-19 pandemic.²⁹⁵ Joint provider/patient groups described telehealth as a “whole new way of working.”³⁷² Patient/caregiver respondent groups were appreciative of clinics providing proactive care immediately after the onset of COVID-19 restrictions,³⁰³ noting that video calling was more valuable than receiving no support at all or only phone consultations.²⁹²

Telehealth was viewed as especially beneficial for certain types of patients, such as those with issues of mobility.³⁷³ Nurses and patients in one study identified a variety of benefits of using telehealth including convenience, saving time and money, and reducing stress.³⁶⁷ Caregivers/parents experienced good or improved communication with providers, highlighting enhanced feelings of connectedness, no waiting time or travel, not having to adjust work schedules/take time off, and not sitting in busy waiting rooms.³⁶⁹ Parent caregivers noted satisfying benefits of gaining time and not having to worry about their child missing school or having behavioral challenges at the hospital, for instance.²⁹⁵

There were no surveys that collected data about general benefits of telehealth from other user groups’ perspectives.

3.5.4.2.1. Patients

Patient satisfaction and confidence with telehealth services varied widely by the type of care and setting in which it was delivered. For example, telehealth for services that required physical manipulation were more burdensome on patients and caregivers than telehealth services that did not require physical manipulation (e.g., telerehabilitation versus teleconsultation). However, patients were satisfied if those healthcare interventions were meant to reduce isolation and improve interpersonal connection^{179, 251, 375, 377, 400, 402–408} (Appendix D Table D.30).

3.5.4.2.2. Providers

Several factors appeared to influence provider satisfaction with telehealth services, such as the type of healthcare provided, availability of home health devices, previous experience with telehealth technology, and established workflows^{179, 245, 251, 324, 383, 392, 395, 403, 405, 406, 409–416} (Appendix D Table D.31).

3.5.4.2.3. Patients and Providers

Telehealth interventions that increased access in target patient populations were acceptable to both patients and providers; however, patients and/or providers agreed that healthcare services requiring a physical exam, manipulation of the patient, or equipment for patient assessment were best supplemented with in-person visits^{245, 375, 379, 396, 404, 406, 409, 411, 412, 414, 416–418} (Appendix D Tables D.30 and D.31).

3.5.4.2.4. Health System

No evidence.

3.5.4.3.1. Patients

Adoption of telehealth services was variable across clinical setting, digital literacy of the patient population, and the urgency with which patients required healthcare services^{251, 374, 375, 377, 379, 397, 399, 402, 406, 419, 420} (Appendix D Table D.30).

3.5.4.3.2. Providers

Adoption of telehealth services was relatively quick among providers; however, the efficiency of adoption depended on prior training of the providers using telehealth services^{245, 251, 278, 290, 324, 383, 385, 387, 388, 392, 395, 400, 406, 414, 421} (Appendix D Table D.31).

3.5.4.3.3. Health System

No evidence.

3.5.4.4.1. Patients

Telehealth showed varying levels of appropriateness across patients. For example, telehealth visits were found to be appropriate for patients requiring timely followups and continuity of care but not suitable for patient populations requiring physical examination, having acute illnesses, or requiring the collection of data from young children^{99, 251, 374, 375, 400, 402, 407, 414, 416, 417, 419} (Appendix D Table D.30).

3.5.4.4.2. Providers

Telehealth was assumed to be mostly appropriate for outpatient visits (e.g., prenatal care, COVID-19 visits); however, those services were found to be not appropriate for specific services (e.g., group therapy, physical examination, or services requiring assistance from a caregiver or participation of young children)^{179, 245, 251, 290, 385, 392, 393, 395, 396, 400, 403, 406, 408, 410, 411, 415, 416, 422, 423} (Appendix D Table D.31).

3.5.4.4.3. Health System

No evidence.

3.5.4.5.1. Patients

Feasibility of telehealth services was sometimes limited by technological challenges, lack of privacy, and missing medical equipment (e.g., thermometers, oximeters) at the patient’s residence^{99, 374, 381, 397, 400, 402, 414, 415} (Appendix D Table D.30).

3.5.4.5.2. Providers

Telehealth reduced the wait times (backlogs), as well as no-shows, hence increasing workplace flexibility; however, certain visit types took longer than planned (e.g., visits that required moving the camera for physical examination)^{278, 383, 392, 397, 399, 411, 413} (Appendix D Table D.31).

3.5.4.5.3. Health System

No evidence.

3.5.4.6.1. Patients

We identified three studies reporting completion of visits by patients^{375, 404, 414} (insufficient evidence).

3.5.4.6.2. Providers

One study discussed the fidelity of visits by providers⁴¹⁶ (insufficient evidence).

3.5.4.6.3. Health System

Various health systems demonstrated the achievement of an acceptable rate of the planned telehealth visits as originally designed, with modest modifications^{179, 245, 387, 388, 397, 423, 424} (Appendix D Table D.31).

3.5.4.7.1. Patients

Two studies calculated the saved costs associated with the receipt of telehealth by patients^{179, 414} (insufficient evidence). None of the studies assessed the penetration of the implementation strategy across other patient populations.

3.5.4.7.2. Providers

None of the studies focusing on providers calculated the incurred or saved costs associated with telehealth implementation. None of the studies assessed the penetration of the implementation strategy across other providers and/or health systems.

3.5.4.7.3. Health System

No evidence.

3.5.4.8.1. Patients and Providers

Sustainability of telehealth services was mostly assessed qualitatively (e.g., intention of patients or providers to use telehealth after the COVID-19 pandemic)^{179, 245, 392, 408, 414} (Appendix D Tables D.30 and D.31).

3.5.4.8.2. Health System

No evidence.