Discussion
Telemedicine has become increasingly important over the past several years and even more so during the COVID-19 pandemic. Telemedicine provides an option for providers and patients to connect in a way that limits possible exposure and conserves personal protective equipment. Without a vaccine candidate, SARS-CoV-2 will likely continue to be a clinical concern even after the immediate pandemic ends.28 Otolaryngologists in particular are at increased risk for occupational exposure to the virus.29–31 It is thus important to consider the broader role telemedicine could fulfill in otolaryngology practices. However, it is equally important to examine how patients view their experience, as patient satisfaction is an important metric of healthcare quality and can play a major role in the long-term acceptance and success of a telemedicine program.32
Previous studies of patient satisfaction with telemedicine across medical specialties have shown that patients are generally satisfied.6,33The few studies in the otolaryngology literature on patient satisfaction with telemedicine also demonstrated a high degree of satisfaction but are limited by small sample sizes and methodology, often using single measures of satisfaction,19,23 non-validated surveys,20 or a selection of items from various satisfaction surveys without independent, final validation.21 To our knowledge, this is the largest study addressing patient satisfaction with telemedicine in otolaryngology and the only study utilizing a validated survey from the larger telemedicine literature. Moreover, this is the first study to examine otolaryngology head and neck patient satisfaction with telemedicine during the COVID-19 pandemic.
The majority of patients reported high satisfaction with telehealth visits, with average scores higher than 5 in the majority of components of the survey. This finding echoes the results of previous telemedicine patient satisfaction studies in otolaryngology.20,23Specifically, patients noted that telemedicine increased access to healthcare services, saved time, and overall met their healthcare needs. Patients also frequently mentioned cost savings.
While the interface quality component of the survey generally received high scores across all three platforms, Item 10 (This system is able to do everything I would want it to be able to do) received one of the lowest averages scores with an average score of 5.27. Several patients who gave it a low score reported that they did so because telehealth visits do not allow for in-depth physical examinations including flexible laryngoscopy rather than considering the capabilities of the platform itself. On this topic, some patients noted that the ability to screen share through one of the platforms (BlueJeans) was an asset in that it allowed the physician to show and explain imaging findings similarly to an in-person visit, a feature not available on the other two platforms. Despite this, the high scores in the three other questions of this component suggest that patients were generally satisfied with the interface quality.  As patients complete virtual consultations across a variety of clinical circumstances, platforms, and specialists, patients will likely become aware of additional ways telemedicine addresses their needs. Careful needs analyses will be necessary in future studies to better capture this component as telemedicine evolves and patient familiarity with telemedicine capabilities increases.
Patients also reported high satisfaction with interaction quality, indicating that the telemedicine visit was effective for provider-patient interactions. Patients indicated that they were able to both easily talk to (average score 6.60, item 11) hear (average score 6.63, item 12), and see (average score 5.91, item 14) the physician.  This stands in contrast to previous work that has found the patient’s ability to clearly hear the clinician is often poor.33,34Notably, the most commonly reported issue with the telemedicine visits was an issue with audio. Once troubleshooted and resolved, patients highly rated the quality of the audio component. In 4 cases, poor interaction quality secondary to issues with connectivity or technical difficulties resulted in the conversion of a video-based telemedicine visits to a telephone call.
The reliability subsection, designed to assess if the telemedicine visit is as reliable as in-person service, also had a low average score. Part of this score is explained by Item 15 (I think the visits provided over the telehealth system are the same as in-person visits), which had the lowest average score (4.02) of the survey. Many patients, after hearing this question added additional narrative comments that visits by telemedicine were not the same due to limitations on physical exam and lack of “human touch”. The other two questions of this section (Items 16 and 17) were commonly answered as not applicable, with many patients indicating that they had no issues or problems at all. Thus, the patients who did rate these statements were the ones with problems, contributing to the lower average score. Other studies have also found low scores on the reliability subsection.33,34This could be explained by the same phenomena observed by the present study or related to other studies that introduced patients to new software that necessitated specific computers and fast internet speeds, which participants did not have.34 By contrast, patients in the present study used Facetime, a platform many routinely use, or relatively simple videoconferencing software on personal electronic devices.
Interestingly, no patients expressed doubts regarding security or quality of care provided by the telemedicine visit. Patients with high satisfaction with quality of care speculated that not all complaints would be appropriate for virtual consultation and that quality is thus circumstance dependent. This is in contrast to consumer market surveys that have demonstrated consumer concerns primarily around security of health information and the quality of care delivered through telemedicine.35 This shift in attitude could represent increasing patient utilization of and comfort with technology as it becomes more prevalent or may be secondary to increased acceptance of the necessity of virtual visits during COVID-19.