Teledermatology Patient Satisfaction in the Pacific Northwest

Abstract

Background: The aim of this quality improvement project is to assess patient satisfaction with a store-and-forward teledermatology project and to identify factors associated with patient satisfaction and dissatisfaction. Subjects and Methods: Veterans receiving care in rural clinics in the Pacific Northwest were surveyed using a 5-point Likert scale about satisfaction with face-to-face care for a skin complaint prior to any teledermatology exposure. One year later, veterans in the same rural clinics were surveyed about satisfaction with teledermatology care using a more comprehensive survey. Ninety-six patients completed the face-to-face satisfaction survey questions, and 501 completed the teledermatology satisfaction survey. Results: Most (78%) of surveyed patients were highly satisfied or satisfied with face-to-face dermatology care. After 1 year of teledermatology, 77% of patients were highly satisfied or satisfied with teledermatology care. The mean patient satisfaction score for teledermatology was equivalent to face-to-face care (4.1±1.2 and 4.3±1.0, p=0.4). Factors associated with teledermatology patient satisfaction included short wait times for initial consultation, a perception that the initial wait time was not too long, a perception that the skin condition was properly treated, and the belief that adequate follow-up was received. Factors associated with teledermatology patient dissatisfaction included perceptions that the skin condition was not properly treated and that inadequate follow-up was received. Conclusions: Teledermatology was widely accepted by the majority of patients receiving care at rural clinics. Patient satisfaction with care received through teledermatology was equivalent to that with face-to-face dermatology.

Introduction

Telemedicine is an increasingly popular method for delivering care to patients with limited access to specialized healthcare, especially in rural areas. With dermatology services in high demand nationally, teledermatology is a partial solution to this service shortage.

We implemented a store-and-forward (SAF) teledermatology project in July 2009 to provide expert-level dermatology care to rural and underserved areas of the Veterans Integrated Service Network 20 (VISN 20), which encompasses numerous communities in the Pacific Northwest. SAF teledermatology is gaining acceptance by the medical community,^{1

–10} but only two published patient satisfaction surveys^7,9 have queried veterans at rural clinics, and more effort is needed to evaluate factors associated with patient satisfaction. The purpose of this quality improvement communication is to report whether patients are similarly satisfied with SAF teledermatology care received via the VISN 20 Rural Teledermatology project compared with face-to-face care and to identify factors associated with satisfaction or dissatisfaction.

Subjects and Methods

VISN 20 Rural Teledermatology Project

From 2009 to 2010, the VISN 20 Rural Teledermatology Project targeted 27 clinics and medical centers in Alaska, Idaho, Oregon, and Washington serving veterans who received primary care at a rural Veterans Affairs (VA) outpatient clinic. We surveyed patients during the first year of our 3-year teledermatology project to enable changing any processes that might improve patient satisfaction. During this first year of the project, 2,641 veterans were consulted using teledermatology.

Teledermatology Process

A primary care provider (PCP) (physician assistant, nurse practitioner, M.D., or D.O.) and an imaging technician make up the remote teledermatology team at each rural VA clinic. The teledermatology referral begins when a skin condition is identified by the PCP. The imaging technician obtains digital images of the lesion(s) and uploads them, together with a brief imaging note outlining the pertinent clinical data, into the VA's computerized patient record system (CPRS). A consult request is generated and transmitted via CPRS to the teledermatology coordinating center in Seattle, WA. The consult request is triaged by the Care Management Coordinator, who assigns new consults to one of five participating board-certified dermatologist consultants.

Once the consult is completed, the consultant enters the differential diagnosis, treatment plan, and PCP follow-up instructions into CPRS. The referring PCP is alerted to the completed consult and is expected to perform the recommended procedures, refer as appropriate for complicated procedures, and assume responsibility for all patient follow-up. The teledermatology coordinating center keeps an internal record of all consults submitted to the VISN 20 Rural Teledermatology Project.

Face-to-Face Dermatology Care Survey

At the launch of the project in July 2009, an internally designed standardized in-person survey was administered to VISN 20 veterans arriving for dermatology care at one of the first four VA clinics receiving initial site training for the teledermatology project. As the other VA clinics began teledermatology participation later in the year and may have included patients transferring from other VA clinics who had started teledermatology earlier, we did not administer the face-to-face survey at these clinics. At the four selected clinics, before the patient received any teledermatology-related care, one of two teledermatology team members (L.V.M. or G.E.R.) administered the satisfaction survey to patients who had received prior face-to-face dermatology care. Basic demographic data were collected, including age and gender but not race or ethnicity. Only those patients who answered yes to receiving care for a dermatology condition existing at least 1 month but no more than 2 years prior to the survey were included in the analysis. They were asked to describe where they received care, how many miles they had traveled to receive care, how long they had waited for an appointment, and their overall satisfaction with prior traditional face-to-face care. Satisfaction survey items were scored on a 5-point Likert scale ranging from highly dissatisfied (score=1) to highly satisfied (score=5). We did not formally attempt to validate our survey questions by correlating them with clinical outcomes, but these survey questions have acceptable face validity, in that they are reasonable and commonsense questions used to measure satisfaction and have been used in previously published studies of patient satisfaction with teledermatology.^6,7,9

Teledermatology Care Survey

From July 1, 2009 to July 31, 2010, 2,641 veterans participated in a four-state teledermatology project at 23 different rural outpatient clinics and healthcare facilities. The patient population served varied widely according to the size of the clinic or facility. To control for this uneven distribution, we stratified the selection of our target survey population by site. First, a list of patients seen by the teledermatology project during the first year was generated for each site, and then a randomized list of patients was generated, using a random number generator to assign a study number. Our goal was to survey approximately 20–25 patients per site. We then attempted to contact consecutive patients until we successfully surveyed 25 patients at each site. For sites with fewer than 20 teledermatology patients, we attempted to survey all the patients. We accessed electronic medical records to obtain contact information (phone numbers). A maximum of three attempts for contact was set. An internally designed, standardized telephone survey was conducted by a single, consistent teledermatology team member (M.T.H.) to assess satisfaction with teledermatology care. Basic demographic data were collected, including age and gender but not race or ethnicity. Survey items included where they received care, how many miles they had traveled to receive care, wait time, and their overall satisfaction with teledermatology. Satisfaction survey items were scored on a 5-point Likert scale ranging from highly dissatisfied (score=1) to highly satisfied (score=5). Additionally, the teledermatology survey asked about preference for teledermatology or face-to-face care, willingness to recommend teledermatology to other veterans, number of teledermatology visits, whether they perceived they were given proper care, receipt of patient education material (printed or verbal), and satisfaction with follow-up care.

Data Analysis

Significance was assessed using a chi-squared test for discrete variables and a Student's t test for continuous variables. Values of p≤0.05 were considered statistically significant.

For the purpose of factor analysis the five Likert categories were collapsed in the following manner. Highly satisfied and satisfied (Likert scores=4 or 5) were combined into a single satisfied group. Neutral (Likert score=3) remained the neutral group. Dissatisfied and highly dissatisfied (Likert scores=1 or 2) were combined into a single dissatisfied group. To identify factors associated with satisfaction and dissatisfaction, responses from each collapsed group were compared with the responses from the neutral group.

Results

Face-to-Face Survey

Of 215 veterans approached, 196 patients (91% response rate) completed the survey about their face-to-face dermatology care, of whom 102 had at least one preexisting dermatologic condition and had received face-to-face care in the previous 2 years. The surveyed population was mostly male (97%) with a mean age of 71±17 years. Of the 96 patients who answered the satisfaction question, 75 (78%) were highly satisfied or satisfied with their previous face-to-face dermatology care (Table 1). The mean patient satisfaction level with face-to-face dermatology care was 4.3±1.0.

Table 1.

Patient Satisfaction with Face-to-Face Dermatology Care and Teledermatology Care

SURVEY QUESTION	FACE-TO-FACE SURVEY	TELEDERMATOLOGY SURVEY	P VALUE
Likert satisfaction rating (n)	(96)	(501)	0.2
(1) Highly dissatisfied (%)	1	6
(2) Dissatisfied (%)	7	6
(3) Neutral (%)	14	11
(4) Satisfied (%)	19	22
(5) Highly satisfied (%)	59	55
Average satisfaction rating	4.3±1.0	4.1±1.2	0.4
Prefer teledermatology to face-to-face care [% (n)]	—	66 (503)	—
Would recommend teledermatology to other veterans [% (n)]	—	83 (501)	—
Average wait time [mean±SD days (n)]
Initial appointment	35.6±40.4 (65)	7.9±9.6 (433)	<0.001
Follow-up appointment(s)	—	10.2±10.6 (294)	—
Average distance traveled [mean±SD miles (n)]	41±69 (98)	54±63 (502)	0.07

A dash indicates data not collected on face-to-face survey.

SD, standard deviation.

Teledermatology Care Survey

From the target population of 2,641 teledermatology participants, a random sample of 631 was selected, providing approximately 27 potential patients per site. Of the 631 selected, 504 completed the survey (80% response rate), and 127 did not. Reasons for non-participation included no valid phone number (n=58, 46%), patient refusal (n=33, 26%), no answer after three attempts (n=30, 24%), inability to hear (n=4, 3%), or died (n=2, 1%). We met our goal of >20 surveyed patients in 19 (83%) of our sites, as four sites had fewer than 20 participants. Of the 504 patients surveyed, most were male (92%) with a mean age of 65±11 years. There were no statistical differences for age or gender distribution or for reasons of non-participation by site. Of 501 veterans answering the satisfaction question, 383 (77%) were highly satisfied or satisfied with their teledermatology care. The mean patient satisfaction level for teledermatology was 4.1±1.2. There is no statistically significant difference in the mean or distribution of satisfaction scores for face-to-face care compared with teledermatology care (Table 1).

Overall, 66% of veterans who received teledermatology care preferred it over face-to-face care, and 83% would recommend teledermatology to other veterans (Table 1). Among veterans who were highly satisfied/satisfied with teledermatology care, 289 (75%) prefer teledermatology to face-to-face care, and 357 (93%) would recommend it to others. Among highly dissatisfied/dissatisfied veterans, 21 (33%) still preferred teledermatology to face-to-face care, and 23 (37%) would recommend teledermatology to other veterans.

Of the 102 surveyed patients who received face-to-face dermatology care, 51 (50%) received care locally, 25 (24%) were referred to distant VA facilities, and 19 (19%) were referred to community private clinicians or care centers. Seventy-four percent of face-to-face care patients were seen within 30 days, and the mean wait time was 35.6±40.4 days. Patients traveled a mean of 41±69 miles to receive face-to-face dermatology care. In contrast, 97% and 93% of teledermatology patients were evaluated within 30 days for their initial and/or follow-up appointments, respectively. The mean wait time was 7.9±9.6 days for an initial teledermatology appointment and 10.2±10.6 days for follow-up appointments. Teledermatology patients waited significantly less time for an initial appointment than those receiving face-to-face dermatology care; however, there was no statistically significant difference in the average distance traveled between the two groups (Table 1).

Of veterans who received teledermatology care, 82% did not think the wait times for the initial or follow-up appointments were too long. Most veterans thought their condition was properly taken care of using teledermatology (79%) and that their follow-up care was adequate (76%). Only 37% of veterans received patient education materials as part of their teledermatology care.

Factors associated with veterans who were satisfied or dissatisfied with teledermatology care were explored. More satisfied patients did not think their wait times for initial appointments were too long (87%) compared with significantly fewer of those who were neutral (69%). Significantly more satisfied patients reported believing their skin condition was properly taken care of (94%) and that they had received adequate follow-up care (89%) compared with neutral patients. Patients who were satisfied had a significantly shorter average wait time of 7.5±8.0 days compared with neutral patients (10.2±11.4 days) (p=0.04). Significantly more patients who were satisfied received educational material (41%) compared with those who were neutral (27%). Several factors were not associated with patient satisfaction compared with those who were neutral: the mean wait time for follow-up care (10.3±10.7 days versus 8.0±7.7 days, respectively), miles traveled to appointments (54±64 and 46±52 miles, respectively), feeling that wait times for follow-up visits were too long, and type of insurance they had.

A significantly smaller proportion of dissatisfied patients thought they received proper treatment (16%) and follow-up (17%), leaving the majority of dissatisfied patients feeling their condition was not properly treated (84%) and that they received inadequate follow-up care (83%). There was no significant difference in initial or follow-up mean wait times for patients who were dissatisfied (6.8±1.2 days and 10.8±11.4 days, respectively) compared with those who were neutral (10.2±1.6 days and 8.0±7.7 days, respectively). Factors not associated with patient dissatisfaction included feeling wait times for initial or follow-up visits were too long, receiving patient educational material, type of insurance, or average miles traveled for visits (54±64 miles), as seen in Table 2.

Table 2.

Factors Associated with Teledermatology Patient Satisfaction and Dissatisfaction

FACTORS ASSOCIATED WITH PATIENT SATISFACTION AND DISSATISFACTION	NEUTRAL [% (N)]	SATISFIED [% (N)]^a	P VALUE	DISSATISFIED [% (N)]^a	P VALUE
Thought skin condition was properly treated	43 (20)	94 (335)	<0.001	16 (9)	0.002
Thought received adequate follow-up	43 (20)	89 (332)	<0.001	17 (10)	0.003
Initial wait time was not too long	69 (34)	87 (308)	0.001	66 (38)	0.7
Received patient education material	27 (15)	41 (157)	0.05	22 (14)	0.5
Follow-up wait time was not too long	78 (25)	84 (219)	0.4	72 (26)	0.6
Have private insurance	61 (33)	60 (230)	0.9	57 (36)	0.7

Satisfied includes “highly satisfied” and “satisfied” responses. Dissatisfied includes “highly dissatisfied” and “dissatisfied” responses.

Discussion

The present study examined satisfaction of veterans with teledermatology and face-to-face dermatology care and identified factors associated with satisfaction and dissatisfaction of teledermatology care.

Patient satisfaction with teledermatology care was equivalent to that with face-to-face care. The high percentage of highly satisfied and satisfied teledermatology patients (77%) in our project is consistent with published literature reporting patient satisfaction with other SAF teledermatology projects, which ranges from 42% to 93%.^1

–9 Sixty-six percent of all patients treated via teledermatology preferred teledermatology to face-to-face care, and 83% would recommend teledermatology to other veterans. It is remarkable that even among dissatisfied patients, 33% still preferred teledermatology, suggesting that patients may still be optimistic about using teledermatology in the future.

Other studies exploring why patients are satisfied with teledermatology frequently cite shorter wait times for teledermatology appointments compared with face-to-face care. Several studies have reported 42–76% of patients prefer teledermatology rather than waiting long times for a face-to-face appointment.^1,4,10 Although the patients may favor face-to-face if wait times are equal among the modalities, the reality is that current wait times for teledermatology care are drastically shorter than face-to-face dermatology care.^1,11,12 In this report, shorter average initial teledermatology appointment wait times were associated with higher patient satisfaction; however, longer wait times for initial teledermatology visits were not associated with dissatisfaction. Longer wait times for follow-up teledermatology visits did not factor into patient satisfaction or dissatisfaction.

Previous studies have reported aspects of care most likely to result in patient satisfaction include receiving a diagnosis, treatment and cure, receiving adequate information and explanations, the need to be taken seriously, the need for individualized personal care, short waiting time for an appointment and treatment,² and patient quality of life.⁸ Williams et al.⁸ reported patients with a lower quality of life are more likely to prefer face-to-face dermatology care over teledermatology. Our study found that both the belief that the skin condition was properly treated and the belief that adequate follow-up was received were associated with patient satisfaction; however, causality could not be established with our data.

Only 37% of patients recalled receiving patient education material. Receiving education material (written or verbal) may be associated with patient satisfaction; however, it was not a significant factor associated with patient dissatisfaction. Accordingly, a stronger emphasis on patient education materials could likely increase patient satisfaction with teledermatology care. We are developing materials and procedures to facilitate administration of patient education and plan to report the results of this intervention in the future.

Few published reports have examined factors associated with teledermatology patient dissatisfaction. Our survey found different factors may be associated with whether a patient is satisfied or dissatisfied with teledermatology care. Patients who were dissatisfied would not recommend it to their peers, and the reasons for dissatisfaction stemmed from feeling that their dermatology issues were not adequately addressed or they did not receive adequate follow-up care. Follow-up may be an important determinant in the success of teledermatology programs, especially in care modalities that rely upon remote consultations.

Limitations of this study include different survey populations for the face-to-face care and teledermatology surveys, with possible recall bias associated with questions requiring the patient to recall past events and timelines. Different survey methods—namely, in-person and telephone—were used for the two surveys and may have posed a threat to the validity of the results. Efforts to reduce these limitations included sampling from the same geographic area and healthcare system (VA) for both surveys, using the same standardized satisfaction questions for both surveys (except for those addressing specific teledermatology aspects), and limiting the number of people doing the surveying. Lastly, the veteran patient population is older and male-dominated compared with the general population, thus limiting the ability to generalize the results to a more diverse population.

In an age where teledermatology can increase patient access to care, it is important to gain the endorsement of patients for this treatment modality. The patient's satisfaction level significantly impacted his or her willingness to recommend teledermatology care to others; thus programs should strive to increase patient satisfaction not only for the direct benefit of the patient, but for the patient support of the modality. Recognizing factors associated with both patient satisfaction and patient dissatisfaction will aid in future program adjustments and ideally further increase overall satisfaction levels.

Footnotes

Acknowledgments

We are indebted to Jeff Rodenbaugh for database programming. G.E.R. is the recipient of a Veterans Affairs Senior Career Scientist award. Funding for the VISN 20 Rural Teledermatology Project came from the Veterans Health Administration Office of Rural Health, U.S. Department of Veterans Affairs. This project was supported by the Veterans Health Administration Health Services Research & Development, U.S. Department of Veterans Affairs.

Disclosure Statement

No competing financial interests exist.

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