A telephone survey of patient satisfaction with realtime telemedicine in a rural community in Colombia

Abstract

We conducted a telephone survey of all patients referred to a realtime telemedicine consultation at the Centre for Telehealth in Bogotá. Over a six-month period, 281 teleconsultations were conducted, and we were able to retrieve telephone numbers for 156 patients. Of these, 121 patients (78%) agreed to answer the questionnaire. Eighty percent of the respondents were satisfied or very satisfied with the teleconsultation and 63% would use telemedicine again. Sixty-five percent thought that telemedicine improved their medical care. More than 50% believed that telemedicine had a positive effect in terms of medical care improvement, time- and cost-savings. Twenty-seven percent felt that teleconsultation was not as good as a traditional face-to-face consultation. Lack of familiarity with ICT did not appear to act as a major barrier to telemedicine, and cognitive factors may be more important in acceptability to patients and their satisfaction. The results of the present study may also be relevant to the poorest countries of the world, where two-thirds of the population live in rural areas.

Introduction

Patient satisfaction is a crucial aspect of the quality of care^1,2 and is a factor in the diffusion and acceptance of telemedicine services.³ Measurement of patient satisfaction has become an important indicator of the performance and outcome of medical services.^2–4 However, there have been few previous studies of patient satisfaction in rural regions of developing countries.

The Centre for Telehealth at Fundación Santa Fe de Bogotá is a non-profit health-care institution, which conducts both synchronous (realtime) and store-and-forward teleconsultations for locations across Colombia. One of its referral hospitals is Centro Ambulatorio Gustavo Escallón Cayzedo (CAM), a rural first-level outpatient institution in the municipality of Madrid (state of Cundinamarca), 28 km from Bogotá, its city of reference, with a population of 67,000 inhabitants.⁵ When the Centre's telemedicine services were first implemented for rural Colombian populations, one of the concerns raised was about patient acceptability among the communities involved, since the country has only 47% Internet connectivity and a low degree of familiarity with ICT.⁶ In this context, we have assessed patient satisfaction with realtime teleconsultations, in terms of medical improvement, time- and cost-savings.

Methods

We reviewed the literature to identify validated tools for measuring patient satisfaction.^7–12 Based on the construct validity, predictive validity, context and feasibility, we selected the survey reported by Hicks et al. ¹³ Other questions were added to obtain demographic data (name, age, sex), information about the teleconsultations (specialty and number of consultations), and data concerning savings in time, money and travel derived from telemedicine compared to a traditional face-to-face consultation. Finally, we allowed free text for comments and additional suggestions. The questionnaire was adapted for telephone administration and reviewed by an expert in telephone surveys, after which some minor adjustments were made.

Participants

All the subjects referred to a realtime telemedicine consultation by CAM from mid-February to the end of August 2009 were considered for analysis. Contact and sociodemographic information for all patients was obtained from the databases of both the Centre for Telehealth and CAM to produce a final list of possible respondents. Patients with no record of a telephone number in the databases, those who refused to answer the survey and subjects with the wrong telephone number or who did not answer the calls were excluded. Participation was voluntary and verbal consent was obtained before the start of the telephone interview.

Survey

The telephone interviews were conducted by two medical interns, who received prior training by an expert on telephone surveys. The interviewers were responsible for undertaking the pilot test calls, making the final phone calls, and recording the data for analysis. Before administering the survey, the questionnaire was translated into Spanish and piloted in a random sample (n = 21, 17% of the total sample) of patients. Pilot testing resulted in various minor adjustments, and the subjects included in the pilot were discarded from the final study analysis.

The database with the total sample was organized alphabetically according to the names of the subjects, and divided into halves, each of which was distributed to the medical students for the telephone survey. Fernandez et al.'s proposed method for conducting telephone surveys¹⁴ was followed for conducting the calls. The method states that after a non-answered first phone call, two further calls are performed at different times of the day. The following events were marked as ‘NO ANSWER’:

No answer for any of the three calls;

The dialled number did not match the patient or there was a change of address;

There was no telephone number recorded in the databases.

For patients younger than 18 years, the questionnaire was administered to a parent or to the adult who accompanied the patient to the consultation.

Statistical analysis

The eight variables of the original questionnaire reported by Hicks et al. were analysed according to the quantitative assessment proposed by the authors.¹³ The answers were scored by the patients on a seven-point Likert scale, and then grouped for analysis according to the criteria shown in Table 1. The three additional questions about the advantages or disadvantages of teleconsultation compared to face-to-face consultation were evaluated according to three qualitative ordinal options: greater, equal or less than. Free comments and suggestions were analysed individually. We performed a chi-square test to validate the results, using the Epidat v3.1 program.

Table 1

Weighting of the responses for the first part of the questionnaire. Patients were asked to reply with numerical scores, rather than nominal ones. After interviewing all 121 patients, we grouped answers to Q1 scored 1 and 2 under ‘Very unsatisfied’, scored 6 and 7 under ‘Very satisfied’, and so on

	Score
Question	1–2	3	4	5	6–7
1	Very unsatisfied	Unsatisfied	Indifferent	Satisfied	Very satisfied
2	Very difficult	Difficult		Easy	Very easy
3	Very little	Little interest		Some interest	Very much
4	Very tense	Tense	A little tense	Relaxed	Very relaxed
5	Not at all	Very little		A little	Very much
6	Not as good		As good as	Better	Much better
7	Very badly	Badly	Indifferent	Well	Very well
8	Not at all	Very unlikely	Indifferent	Yes	Very much

Results

During the study period, 281 teleconsultations were conducted, and we were able to retrieve telephone numbers for 156 patients. A total of 121 patients (78%) agreed to answer the questionnaire and 35 (22%) refused to participate in the study (Tables 2 and 3). The respondents were aged 4–98 years. Of the 121 patients who answered the survey, 90 had attended a single consultation and 31 had attended two or three teleconsultations in the six-month period. The teleconsultations concerned dermatology (82, or 68%) and general surgery (39, or 32%). The other demographic characteristics of the respondents are summarised in Table 4.

Table 2

Gender of the subjects answering the survey

	Refused	Agreed	Total
Female	13	96	109
Male	6	41	47
Total	19	137	156

Table 3

Specialty of the subjects who answered the survey

	Refused	Agreed	Total
Dermatology	26	82	108
Surgery	9	39	48
Total	35	121	156

Table 4

Demographic information about the patients surveyed

Gender	No.	%
Female	84	69
Male	37	31
Total	121	100
Age average	Mean (years)	SD
Overall	51	19
Female	53	16
Male	47	25
Age range (years)	Lowest	Highest
Overall	4	98
Female	12	98
Male	4	86
Specialty	No.	%
Dermatology	82	68
Surgery	39	32
Total	121	100
Number of consultations per patient	No.	%
One	90	74
More than one	31	26
Total	121	100

The answers to the first eight questions of the questionnaire are summarised in Table 5. In general, most respondents rated the service with the two highest scores, 6 and 7. The question ‘do you think your telemedicine session was as good as an ordinary in-person visit?’ obtained the lowest score: 27% of respondents felt that teleconsultation was not as good as face-to-face consultation; 39% considered teleconsultation as good as an ordinary consultation and 34% believed it was better or much better. However, 80% of the respondents were satisfied or very satisfied with the teleconsultation and 63% would use telemedicine again. As for the doctor-patient relationship, 93% of the respondents felt that it was easy or very easy to communicate with the doctor, and 90% agreed that the physician showed much or very much interest in the patient as a person during the teleconsultation. Among the 31 patients who had attended more than one teleconsultation, 65% thought that telemedicine improved their medical care, and 35% thought that there was little or no improvement. In terms of money, travelling and time costs, more than half of the respondents believed that telemedicine had a positive effect, producing savings in these three aspects (Table 6).

Table 5

Results from the first part of the survey. Values shown are the number of answers according to each score (%)

	Score
Question	1	2	3	4	5	6	7
1. Overall, how satisfied were you with today's telemedicine session?	5 (4)	8 (7)	6 (5)	5 (4)	19 (16)	30 (25)	48 (40)
2. How easy was it to talk with the telemedicine provider?	3 (3)	2 (2)	1 (1)	3 (3)	19 (16)	21 (17)	72 (60)
3. How much did the telemedicine provider seem to care about you as a person?	1 (1)	1 (1)	8 (7)	2 (2)	20 (17)	38 (31)	51 (42)
4. Did you feel relaxed or tense during the telemedicine session?	7 (6)	4 (3)	7 (6)	12 (10)	34 (28)	39 (32)	18 (15)
5. Do you think telemedicine improves your medical care?	1 (3)	1 (3)	3 (10)	6 (19)	6 (19)	11 (36)	3 (10)
6. Do you think your telemedicine session was as good as an ordinary in-person visit?	13 (11)	7 (6)	13 (11)	47 (39)	17 (14)	11 (9)	13 (11)
7. How well did the telemedicine equipment work today?	2 (2)	0 (0)	0 (0)	5 (4)	12 (10)	29 (24)	73 (60)
8. Would you want to use telemedicine again?	16 (13)	2 (2)	9 (7)	6 (5)	12 (10)	31 (26)	45 (37)

Table 6

Results from the second part of the survey. The values are the number of answers for each option (%)

	Option 1 (greater costs; increased waiting time; more travel required)	Option 2 (same costs; same waiting time; same travel required)	Option 3 (lower costs; reduced waiting time; less travel required)
In terms of cost savings, telemedicine generated:	4 (3)	45 (37)	72 (60)
In terms of the time between requesting the appointment and the consultation itself (waiting time), telemedicine generated:	20 (17)	35 (29)	66 (55)
In terms of distance and travelling to reach the site where the consultation took place, telemedicine generated:	2 (2)	38 (31)	81 (67)

Of all respondents, 66 (56%) made an additional comment or suggestion during the interview. Among these, 25 patients (38%) made positive comments confirming their satisfaction with the service; 17 (26%) confirmed that they preferred face-to-face consultation; six (9%) complained about the high cost of some of the dermatology drugs prescribed by the doctor; five (8%) complained about technical problems during the session (Internet connection, sound, electronic health record system); two (3%) complained about the survey itself and the rest of the comments (n = 11, 17%) were related to administrative matters (e.g. the process of appointment request) or unrelated matters. The average age of the respondents who preferred face-to-face consultation was 52 years and most of them (n = 14, 82%) were women; however that difference was not significant (chi-squared = 0.234; df = 1; P = 0.629).

Discussion

Few studies have evaluated the impact of telemedicine in Latin America.^15–18 Most of them have focused on the rate of use, economics and diagnostic accuracy. Telemedicine has been shown to be a cost-effective, economically viable and beneficial way of supplying specialist care in South America.¹⁹ Nevertheless, there have been no reports, to our knowledge, of patient satisfaction with telemedicine in this region. One study conducted in Perú¹⁸ measured the reliability of a telemedicine system and its effect on health staff access to medical training and information. According to this study, health-care personnel reported that ‘the use of the system saved the life of the patient’ and that ‘the use of communication technologies appropriate to local needs solves many problems in rural primary care’. However, the sample only included 31 subjects, and patients' perceptions were not assessed. Another study examined perceptions about telemedicine among underserved African-American and Latino populations in Los Angeles. Telemedicine had several advantages compared to usual health care, including: (1) reduced waiting time; (2) immediate feedback about diagnosis and course of action; (3) increased access to specialists; and (4) increased access to multiple medical opinions.²⁰ In general, African-Americans tended to identify more concerns and fewer advantages, whereas Latinos had the opposite tendency. Other perception studies undertaken in non-Latin American developing countries, underserved areas or rural contexts have also primarily focused on health-care staff rather than patient satisfaction.^21–23 Two studies conducted in remote Cambodia, however, assessed the satisfaction rate among 63 adult patients with email-based telemedicine, and found that the majority were satisfied or very satisfied with their experience of the telemedicine service.^24,25 Nevertheless, satisfaction was not defined and therefore, as described by Mair and Whitten,²⁶ it is not possible ‘to discern whether the participants said they were satisfied because telemedicine didn't kill them, or that it was okay, or that it was a wonderful experience’, i.e. it is not possible to understand the reasons underlying satisfaction.

Health-care delivery via telemedicine services was highly accepted among the population we studied. As reported by others,^8–13,26 we found an overall high level of satisfaction with telemedicine, in our case above 80%. This may have been related to the high response rate (78%), which may indicate an expectation among the subjects that the service would be extremely useful (rated with the highest possible scores in the telephone survey). These results are important in the context of the sociodemographic characteristics of the population under study: not only were the subjects rural in origin, but also more than half of them were aged over 50 years, and had high limitations in terms of access to and familiarity with ICT. Overall, the illiteracy rate among the studied subjects was 6%⁵ and connectivity rates in Colombia are still below 47%.⁶ It was not surprising, however, that a substantial proportion of patients (27%) still preferred the traditional face-to-face consultation compared to teleconsultation. Some factors that may influence patient satisfaction in our local context were: age (older adults may be more reluctant to participate in teleconsultation); rural origin (due to higher rates of illiteracy and lower ICT access and ‘culturization’);²⁷ lack of information for patients on how teleconsultation works; low perception of safety by the patient when he/she is attended by a remotely-located physician via a ‘television screen’, and technological and communication barriers.

In analysing the results from the present study, we may infer that user satisfaction with telemedicine is closely related to emotional and psychological barriers rather than technical ones.²⁸ Further research is needed to elucidate which specific cognitive factors are most important in rural contexts and how to approach them to ensure the success of telemedicine. In the present study, most subjects (74%) had used the telemedicine service only once. This leads us to speculate that teleconsultations are well suited for initial (first-time) appointments. Moreover, the fact that almost 65% of the patients who attended more than one teleconsultation believed that telemedicine improved their medical care implies that telemedicine may also be suitable for follow-up appointments. It would be worth undertaking future assessments to confirm this supposition.

In terms of money, travelling and time savings, telemedicine was perceived to have positive consequences by the majority of respondents (60%, 55% and 67%, respectively). This may be explained by the fact that telemedicine brings access to specialists who would otherwise only be reachable by patients after a long, inconvenient and costly journey to the specialist health-care institution, in this case 1.5 hours away in Bogotá. However, it would be desirable to conduct a proper economic analysis of these matters to allow more reliable conclusions to be drawn.

As for the doctor-patient relationship, more than 90% of the respondents were satisfied with the communication and the attention they received from the specialist, showing that telemedicine did not seem to change the quality of this contact as perceived by the patient. Although our study sample represents only a small proportion of Colombia's rural population, we believe our results may reflect patient satisfaction with telemedicine services in the rural populations of Colombia generally, since connectivity and familiarity with ICT are similar. The results may also be relevant to the poorest countries of the world, where two-thirds of the population live in rural areas.²⁹ As Internet access and telemedicine services continue to spread, satisfaction rates may further improve. However, in order to obtain more generalizable results, further studies should be conducted not only in the other remote areas of Colombia, but also in other developing countries.

Limitations

In the present study, respondents received telemedicine consultations in only two specialties, surgery and dermatology. It is important to assess the satisfaction of patients treated in other specialties. It is also important that a larger population of patients drawn from various municipalities of Colombia should be studied. As stated elsewhere,^{9–13,26,27,30,31} there are not enough reliable and validated tools to assess telemedicine consistently, and new forms of satisfaction assessment need to be developed.

Conclusion

Telemedicine services in the rural context studied were highly valued by the patients. Lack of familiarity with and access to ICT did not appear to act as a major barrier. Cognitive factors may be more important in acceptability to patients and their satisfaction. This is important since telemedicine constitutes a method of improving access to health-care services where they are most limited, i.e. in remote and rural areas, and developing countries. As connectivity and telemedicine services continue to expand in Colombia, further studies that include more users from different remote populations should be undertaken to produce nationally-representative results. Similar studies in other developing countries should also be undertaken. Studies that objectively assess the clinical effects and quantify the monetary and time savings derived from telemedicine services in rural populations are also needed. The present study contributes to the limited literature about the acceptability of telemedicine among vulnerable populations, and to our knowledge, provides the first data on patient satisfaction with realtime teleconsultations in a rural Latin American setting.

Footnotes

Acknowledgements

We thank the telemedicine team at Centro Ambulatorio Gustavo Escallón Cayzedo and its Director, Martha Cecilia Ortiz, for their support.

References

Donabedian

. The quality of care. How can it be assessed? JAMA 1988;260:1743–8

Wensing

, Elwyn

. Research on patients' views in the evaluation and improvement of quality of care. Qual Saf Health Care 2002;11:153–7

Agha

, Schapira

, Laud

, McNutt

, Roter

. Patient satisfaction with physician-patient communication during telemedicine. Telemed J E Health 2009;15:830–9

Fitzpatrick

. Surveys of patient satisfaction: important general considerations. BMJ 1991;302:887–9

Madrid. See http://madrid-cundinamarca.gov.co/nuestromunicipio.shtml?apc=m1y-1935643-1935643&m=i (last checked 21 September 2010)

Internet World Stats. Usage and Population Statistics. See http://www.internetworldstats.com/sa/co.htm (last checked 6 July 2010)

Yip

, Chang

, Chan

, MacKenzie

. Development of the Telemedicine Satisfaction Questionnaire to evaluate patient satisfaction with telemedicine: a preliminary study. J Telemed Telecare 2003;9:46–50

Braun

, Kreimeier

, Greiner

. Measuring patient satisfaction in integrated health care projects – a pilot study with a modified ZAP questionnaire. Z Evid Fortbild Qual Gesundhwes 2010;104:106–12 [German]

Collins

, Nicolson

, Bowns

, Walters

. General practitioners' perceptions of store-and-forward teledermatology. J Telemed Telecare 2000;6:50–3

10.

Styles

. Service users' acceptability of videoconferencing as a form of service delivery. J Telemed Telecare 2008;14:415–20

11.

Gustke

, Balch

, West

, Rogers

. Patient satisfaction with telemedicine. Telemed J 2000;6:5–13

12.

Whitten

, Mair

. Telemedicine and patient satisfaction: current status and future directions. Telemed J E Health 2000;6:417–23

13.

Hicks

, Boles

, Hudson

, Patient satisfaction with teledermatology services. J Telemed Telecare 2003;9:42–5

14.

Fernandez

, Lopez

, Monsalve

, Zarante

. Telephonic follow-up of patients with genitourinary malformations in their first two years of life. Urol Colomb 2008;17:9–14 [Spanish]

15.

Altrudi

, Eurnekian

, Gandsas

, Silva

, Silvestri

. Videoconferencing as a medical educational tool: first experience in Argentinean public hospital. Stud Health Technol Inform 1998;50:364–5

16.

Rendón

, Martínez

, Dulcey

, Rural telemedicine infrastructure and services in the Department of Cauca, Colombia. Telemed J E Health 2005;11:451–9

17.

Rodas

, Vicuna

, Rodas

. Telemedicine and mobile surgery in extreme conditions: the Ecuadorian experience. Stud Health Technol Inform 2004;104:168–77

18.

Martínez

, Villarroel

, Seoane

, del Pozo

. A study of a rural telemedicine system in the Amazon region of Peru. J Telemed Telecare 2004;10:219–25

19.

Keane

. Review of the use of telemedicine in South America. J Telemed Telecare 2007;13(Suppl. 1):34–5

20.

George

, Hamilton

, Baker

. Pre-experience perceptions about telemedicine among African Americans and Latinos in South Central Los Angeles. Telemed J E Health 2009;15:525–30

21.

Chattopadhyay

. A framework for studying perceptions of rural health-care staff and basic ICT support for e-health use: an Indian experience. Telemed J E Health 2010;16:80–8

22.

Palmas

, Teresi

, Weinstock

, Shea

. Acceptability to primary care providers of telemedicine in diabetes case management. J Telemed Telecare 2008;14:306–8

23.

Tudiver

, Wolff

, Morin

, Primary care providers' perceptions of home diabetes telemedicine care in the IDEATel project. J Rural Health 2007;23:55–61

24.

Heinzelmann

, Jacques

, Kvedar

. Telemedicine by email in remote Cambodia. J Telemed Telecare 2005;11 (Suppl. 2):44–7

25.

Brandling-Bennett

, Kedar

, Pallin

, Jacques

, Gumley

, Kvedar

. Delivering health care in rural Cambodia via store-and-forward telemedicine: a pilot study. Telemed J E Health 2005;11:56–62

26.

Mair

, Whitten

. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000;320:1517–20

27.

Kolitsi

, Iakovidis

. Improving user acceptance of health-care telematics. J Telemed Telecare 2000;6 (Suppl. 2):37–9

28.

Buck

. Nine human factors contributing to the user acceptance of telemedicine applications: a cognitive-emotional approach. J Telemed Telecare 2009;15:55–8

29.

Population Reference Bureau. 2005 World Population Data Sheet. See http://www.prb.org/pdf05/05WorldDataSheet_Eng.pdf#search=%22south%20america%20population%20data%22 (last checked 6 July 2010)

30.

Scott

, McCarthy

, Jennett

, Telehealth outcomes: a synthesis of the literature and recommendations for outcome indicators. J Telemed Telecare 2007;13 (Suppl. 2):1–38

31.

Williams

, May

, Esmail

. Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature. Telemed J E Health 2001;7:293–316