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Presentation

Exploring Opportunities to Improve Patient and Provider Experience with Telemedicine Appointments in Female Pelvic Medicine and Reconstructive Surgery
Event Type
Poster Presentation
TimeThursday, April 152:00pm - 3:00pm EDT
LocationHospital Environments
DescriptionIntroduction/Background:
As a result of COVID-19, medical providers across the nation have started rapidly adopting telemedicine; however, the introduction of a new technology into an already complex system creates new challenges that have the potential to negatively impact patient and provider experience. Factors that were once irrelevant, like internet connectivity, become significantly more important. Consequently, if systemic barriers (e.g., unclear instructions, poor connectivity, inability to see or hear their physician) exist, patients are unlikely to have positive visit experiences and may not feel satisfied regardless of the quality of their care. Before the pandemic increased the need and reliance on telemedicine to treat patients in a safe way, there was a general unwillingness among clinicians to adopt telehealth as it has been perceived as disruptive, and fatiguing.
Traditionally urologists have embraced new technology from lasers to robotic surgery, so it is no surprise that the American Urological Association reported on its use of telehealth in 2016. But as urologists have learned with other technologist, challenges associated with implementing telemedicine practices make it imperative to understand the current state of the telemedicine system and identify opportunities to improve patient and provider experience. The goal of this study was to use a human factors approach to identify existing systemic vulnerabilities throughout the patient/provider experience with telemedicine and develop data-driven interventions to improve the process.

Methods
This prospective, observational study was deemed exempt by the Institutional Review Board. Researchers conducted observations of patient telemedicine training, telemedicine visits, and surveys aimed to investigate telemedicine experiences. The providers in the study include three Female Pelvic Medicine and Reconstructive Surgery fellowship trained urologists.
A trained human factors researcher observed ten patient training experiences to understand the training process and identify opportunities for improvement. The researcher documented steps involved with the training, average training duration, patient questions, and challenges. Subsequently the researcher observed patient-provider visits conducted via telemedicine and documented the visit duration and any process inefficiencies or observable events that disrupted the efficiency and flow of the visit (e.g., communication breakdowns, connectivity problems, poor device setup and interruptions). Following the visit, patients and providers were invited to take a voluntary survey regarding their satisfaction, perceived usability of the system and suggestions for improvement.

Results
Each of the 10 patient training sessions lasted an average of six minutes. Most time was spent instructing patients on how to create a hospital profile account and download the necessary application for their device. Six patients (60%) had previously activated their hospital profile account and did not require setup instructions. However, only one patient (10%) had already downloaded the associated application for their smart phone. Instructions varied between training sessions. In five of the visits (50%) patients were instructed to arrive to the virtual waiting room 5-10 minutes prior to the appointment time. However, in four visits (40%) this information was not conveyed.
Twenty-three patient visits with one of three physicians were observed, lasting an average of 17.3 min, with six process inefficiencies each (138 total). Process inefficiencies were categorized into 10 major categories: communication breakdowns (23, 16.67%), interruptions (21, 15.22%), internet connectivity (21, 15.22%), and non-optimal setup (19, 13.77%). In four of the visits (17.39%) the telemedicine platform could not be used due to patient confusion issues, and physicians resorted to calling patients from their cell phones.
Providers completed surveys after every patient interaction (n=23). The average satisfaction score was 3.72 out of 5.00. The average SUS score was 63.15, indicating a below average perceived usability. Six of the 23 patients (26%) completed the voluntary post-visit survey. All patients had prior experience with video conferencing and five (83.33%) had prior experience with telemedicine. When asked about their general satisfaction with the telemedicine system, the average score was 4.83 out of 5.00. The average SUS score was 85, indicating a higher-than-average perceived usability.

Discussion
The goal of this pilot study was to investigate patient and provider experiences with telemedicine visits in a urology practice. The findings of this study highlight opportunities to improve the training process, patient experience, and provider experience associated with implementing a telemedicine program.
Observations of patient training identified several opportunities for improvement. First, there were inconsistencies in how patients were trained as some received more detailed information than others, and trainers were not knowledgeable about the types of devices that were compatible with the platform. Possible interventions to improve training might include a pre-telemedicine visit information sheet that includes steps for setting up an account, and helpful tips to improve the quality of the telemedicine experience. Additionally, a checklist for the front office staff may prove to be beneficial.
Observations of the telemedicine visits also revealed several opportunities to improve experience and reduce inefficiencies. Many issues stemmed from communication breakdowns. Training providers to communicate more effectively and clearly, using closed-loop communication techniques, may help to reduce the number of communication breakdowns observed. Interruptions like alarms, alerts, and extraneous conversations also represented a large amount of the disruptions. It may be beneficial to provide a training or information sheet to patients and providers about how to setup an interruption-free environment. Internet connectivity was another major disruption. While difficult to address, there are some suggestions that could be made to both patients and providers to enhance connectivity prior to and during the appointment (e.g., limiting file uploads and downloads during the visit, sitting near the router, and closing other applications that are running on a device). Finally, not having an optimal setup caused several issues for providers when attempting to engage with patients during video visits. Because the platform is only accessible on a smart device (e.g., an Apple or Android cell phone) providers had to find a way to position their devices (often while being charged) so that they could communicate with the patient and take notes. This often led to poor visualization of the patient or awkward, uncomfortable sitting positions for the providers. Phone stands or charging stations could be used to promote more optimal setups for providers.
Regardless of experiencing several inefficiencies during the visits, patients reported high levels of satisfaction and perceived the telemedicine platform to be usable, especially when compared to providers. Notably, the high education level and previous experience with video conferencing and telehealth likely positively impacted the patients’ experience. Providers were less satisfied, especially with their ability to interact with, see, and hear the patient during the telemedicine visits. Given that the system was implemented rapidly to meet the demand to see and treat patients while maintaining social distancing practices, it was an appropriate mechanism to host clinic visits with urologic patients. Benefits of telemedicine in a urology practice include access (allowing video visits outside of regular office hours), reduced commute time for patients and providers, and streamlining of a urology practice so that in-office visits are more procedural. Although implemented in a state of emergency, we are hopeful that telemedicine in urology is here to stay and with the application of human factors engineering, we hope to improve the process for both patients and providers.