The Covid-19 pandemic presented new challenges and opportunities for patients, their families, and healthcare professionals while also speeding up the current process of digital transformation in healthcare [79]. As telemedicine will increasingly become an integral component of healthcare services provision, it's important to understand front-line staff perception and experience with its use. In this paper, the perceptions of healthcare professionals and managers on benefits, challenges and drivers to the implementation of telemedicine services have been explored across the Italian NHS during the pandemic period.
We found that both healthcare professionals and managers believe that using telemedicine services can positively impact patient care and operational and organisational aspects. This is in line with other studies exploring clinician perspectives on telemedicine during the Covid-19 crisis [33, 61, 64].
As expected, study participants agreed that the rapid adoption of telemedicine services throughout the Covid-19 pandemic was mainly due to the need to respond to the emergency by reducing face-to-face contact [67, 68, 80, 81].
Findings also confirm previous studies showing how regulatory aspects are a barrier to the adoption of telemedicine and how easing these barriers can facilitate the implementation of these services [82–89]. The use of telemedicine has remained relatively limited in recent years due to several regulatory obstacles, such as poor reimbursement regulations, complex technology purchasing processes, and a lack of data governance and privacy guidelines [64, 90]. Remote contact-specific data privacy regulations were absent in many countries before the epidemic and then implemented [64, 91]. Similar to this, particular data protection regulations for telemedicine that were not previously available in most situations became available during the pandemic [64, 84–88, 92–95]. Moreover, before Covid-19, most regional healthcare systems and insurance providers didn't pay for telemedicine consultations [64]. However, although in many countries changes in national and local regulations during and beyond Covid-19 have introduced specific reimbursements for telemedicine services and improved data protection and privacy for telemedicine, concerns about these issues have been still reported in recent studies by physicians as a major challenge to the adoption of telemedicine [61, 63, 64, 91]. During the pandemic, local, national, and international governments around the world also used financial incentives to encourage healthcare providers to adopt telemedicine services, such as grants for technology acquisition and implementation. This is reflected in our findings revealing that, differently from previous literature [96], the availability of financial resources to acquire or implement telemedicine services was not regarded as a key driver of adoption during the pandemic.
According to previous literature, respondents perceive telemedicine as useful in improving patient care even beyond the pandemic crisis [66, 97–99]. The possibility to enhance patient care, improve operational aspects and reduce travel for patients and healthcare professionals were perceived as key benefits of the use of telemedicine both during and beyond the pandemic period. Our findings corroborate those of other studies that found telemedicine to have positive effects on follow-up care efficiency, the ability to see patients more frequently when necessary, improved rapidity of care delivery (shorter wait times for appointments, shorter consultation times), and a reduction in missed appointments [14, 55, 61, 82, 86, 93, 95, 100–103]. Through telemedicine, patients can avoid travelling to and from appointments, taking less time off work, or waiting in waiting rooms. Avoiding travel saves time and money on parking, transportation, childcare, or other carer costs. Patients who face physical or financial obstacles to access, such as the elderly, those with mobility issues, people who live in remote locations, and people with low incomes, stand to benefit especially from this [61, 82–85, 94, 95, 100–106].
Our findings also corroborate previous research describing how telemedicine can improve the quality of work of healthcare professionals as telemedicine gives doctors more flexibility with their schedules and patient availability [61]. Moreover, remote working allowed those who were more at risk of contracting the virus during the pandemic period to continue working (such as senior physicians).
In line with previous literature, participants concurred that telemedicine could improve patient access to care, particularly for individuals who reside in rural, underdeveloped, or resource-constrained locations [55, 63, 82, 83, 92, 93, 95, 101, 103, 105–107].
Regarding improving operational and organisational aspects, findings confirm previous literature demonstrating telemedicine's positive impact in reducing patient waiting lists and ED attendance [108–111].Participants also believe that adopting telemedicine services could potentially lead to an overall improvement in administrative and care processes. However, some of them expressed concerns about poor coordination of workflows leading to duplication of tasks and additional burdens for clinicians. According to earlier research, the burden of telemedicine can be related to the challenges of integrating telemedicine into routine clinical practice, the complexity and lack of interoperability of platforms, poor data integration among devices, and the requirement for additional time for virtual consultations [14, 64, 82, 88, 89, 103, 105, 112–114]. Other studies described how telemedicine services led to the duplication of visits when the virtual assessment was insufficient [61], or to an increased workload for clinic administrative personnel to coordinate access to virtual treatment (including assisting patients and caregivers in choosing between phone and video conferences and facilitating technology troubleshooting) [67].
Moreover, most respondents agree that telemedicine services can't completely substitute patient-clinician and clinician-clinician face-to-face interactions throughout the care process. Only a few respondents (7%) perceive telemedicine services as more effective in delivering better patient outcomes than traditional (face-to-face) care. Our findings corroborate previous literature reporting that this is mainly due to challenges with the patient-doctor relationship, cases in which physical examination is needed or recommended, and the organisation of clinical work [27, 28, 33, 40, 66, 114–117].
Difficulties related to the decreased ability to perform physical examinations have been widely reported in other studies exploring the healthcare professionals' perspective on the use of telemedicine [61, 63]. Clinicians believe that while there are some situations in which face-to-face consultations can be avoided, such as those in which a diagnosis can be made based mainly on the patient's medical history (i.e., no physical examination is required), there are other circumstances in which a physical examination is necessary or advised [63, 118]. Recent papers describe the attempt to solve this issue by releasing instructions for efficient virtual examinations [119, 120]. However, physical examination is essential not only for efficient clinical practice - it is also an integral component of the doctor-patient therapeutic connection [61, 121]. Studies have also drawn attention to the possibility that telemedicine technologies could jeopardise the continuity of treatment and the therapeutic relationship, two features of care delivery crucial to clinical practice that have significant implications for patients and doctors [27–29, 61]. Effective treatment of mental, emotional, and behavioural health issues depends on the relationship between the patient and the clinician [29]. The Covid-19 pandemic has highlighted the importance of establishing social connections remotely for therapeutic human relationships in addition to assuring the safety and effectiveness of care delivery [28, 29]. In a virtual care context, maintaining continuity of care and establishing therapeutic relationships with patients necessitates learning new techniques for establishing deep connections through everyday interactions [29].
Our findings also show how these concerns and obstacles associated with technology-mediated communication between patient and doctor, as well as issues concerning poor quality and difficulty with technology use, can have a detrimental impact on clinician trust in telemedicine and its widespread adoption [66].
According to earlier studies, a major obstacle to the adoption of telemedicine is related to technological limitations faced by both patients and healthcare professionals [61, 64, 82, 86, 89, 90, 95, 101, 113, 122]. This is especially true when using virtual tools to make diagnoses and the difficulty of learning new software while under time constraints at the beginning of the pandemic [61]. The impact of technological obstacles on both patients' access to care and doctors' ability to deliver high-quality care should not be underestimated. This is consistent with research findings showing that some patients and providers face technological literacy and logistical challenges when participating in telehealth visits, particularly given the variety of technologies available and/or the ways in which some medical practices have shifted technologies [27, 40, 117]. Previous studies show how patients' concerns with telemedicine are related to a lack of knowledge and skills to use these technologies effectively, restricted access to the necessary equipment (e.g. cameras, email, smartphone), limited access to the internet and difficulties with installing applications [61, 63, 66]. A commonly reported remedy when a patient is unable to connect for a video appointment is switching to a phone conversation, as this was the most straightforward option for both doctors and patients [61, 67]. However, this is not a desirable option as, according to research, the lack of visual information limits clinicians' capacity to evaluate the patient's condition (literacy, language barrier, difficulty asking/responding to inquiries, etc.) and the patients' '" homes" actual surroundings, causing diagnostic difficulties [61, 66, 67].
Finally, our findings show that although healthcare professionals perceive a positive attitude of patients toward telemedicine, they believe several barriers need to be overcome to improve equity of access and use. Our results corroborate a large body of literature showing that problems with access and use of the technologies are exacerbated for specific groups of people, such as older adults, people with hearing impairment, disabilities or other vulnerabilities (e.g., low-income) as well as for people not speaking the local language [82, 104, 106]. In line with our findings, these studies emphasise the critical role of caregivers in assisting patients with technological challenges, the description of the medical history and the development of a treatment plan, which is especially necessary when seeking virtual care [67].
4.1 Implications
With this study, we contribute to a growing body of literature exploring the use of telemedicine from the front-line staff perspective during the Covid-19 pandemic. Because the increasing use of telemedicine during the pandemic drastically impacted how care services were provided, this study allowed us to gather staff perspectives in a different situation compared to earlier studies. We believe that our findings are generalisable since our survey included individuals from various Italian areas and application contexts in terms of medical specialisations and technologies.
Findings from this study suggest that, while telemedicine cannot completely replace face-to-face care, it can improve patient care, patient experience, and operational and organisational performance if used in conjunction with traditional care practices. As telemedicine grows in parallel with the continued use of face-to-face visits, it is critical to develop strategies to ensure that this mode of care delivery is secure and equitable in both routine and emergency scenarios.
At the start of the pandemic, regulatory structures were ambiguous and fast-changing [63]. However, as more providers have turned to telemedicine, policies and laws governing it have grown clearer and more standardised [82–89, 96, 123]. In accordance with other post-pandemic literature, our findings suggest that regulatory barriers are still a challenge for the wider spread of telemedicine [63, 64, 91]. Additional standards and regulations are required as the industry evolves, as some of those in place were only temporary during the Covid-19 outbreak [2]. A greater effort should be made by governments and regulatory bodies to enhance data protection and privacy and provide clearer rules and guidance on the reimbursement of telemedicine services. Moreover, technology access could be improved by retaining and upgrading measures established during the pandemic to ease purchase processes and by keeping supporting technology acquisition and implementation financially.
Although there is general agreement about how virtual and in-person care will play roles in supporting patients in the future, more guidance is needed to help clinicians, patients, and caregivers understand how to safely and effectively integrate virtual care into practice [33, 124, 125].
Further guidelines should be developed by national and international medical associations and scientific communities to indicate evidence-based practices for the use of telemedicine in different medical specialities. These guidelines should outline criteria to suggest cases where telemedicine is more appropriate and where instead, a physical examination is needed or recommended [110, 126]. The availability of evidence-informed guidance would improve clinician trust in the use of the technology and eventually lead to increased efficacy and efficiency of care by avoiding the repetition of visits for cases where virtual care was not the preferable care modality [67].
Care and administrative process efficiency could be further improved by reducing the heterogeneity of the digital platforms and by making sure that tools used within each remote care process are interoperable [63, 64]. Moreover, as the stress placed on healthcare systems by the emergency crisis relaxes, greater attention might be paid to redesigning and standardising workflows, as well as redefining roles to optimise the use of virtual care alongside traditional care services [33, 64, 68, 127–130].
Guidance and regulations should also be developed to increase the equity of access to care for specific groups of patients who might have considerable issues accessing and using telemedicine services. For example, in November 2022 the Italian Government published the "National guidelines for telemedicine services – functional requirements and service levels" aimed at improving equity of access and efficiency of telemedicine by outlining patient eligibility criteria for virtual care based on individual patient characteristics, such as clinical aspects, availability of the required technology, digital literacy, patient autonomy or presence of a caregiver [131]. [REF] Although this represents a significant step forward, many challenges still need to be faced with implementing these guidelines in practice.
Poor digital literacy and difficulty in using telemedicine technologies are still major challenges to the effective use of telemedicine [64, 84, 90, 122]. More assistance is required to facilitate video visits for patients and professionals. Clinical educators should focus on integrating new telemedicine competencies into learner curricula and practice. Telemedicine education for healthcare professionals should emphasise integrating learners into workflows and assisting patients in navigating virtual visits by incorporating patient-centred care principles [66]. This training should encompass the social and emotional components of care delivery to provide clinicians with guidance and skills for remotely nurturing and developing the patient-physician relationship, especially with new patients [61]. On the patient side, creating patient-facing materials to assist patients in preparing for and navigating virtual sessions (e.g. pre-visit information on camera/body placement, clothes, and setting) has also been suggested as an effective approach to improve the efficiency and quality of telemedicine visits [132, 133].
Other approaches to reducing potential disparities in care access include expanding the availability of telemedicine services to increase patient choice, providing technologies at reasonable prices for people in need, offering different language options and involving caregivers as much as possible in the care process.
To close the digital divide, organisations must look deeper into their patients' telehealth experiences and engage them in identifying the constraints that impede their capacity to participate in video sessions [67, 134]. In this study, we did not directly survey patients, and all identified benefits and challenges, as well as perceptions, are based solely on clinician experience. Future research could elicit these perceptions directly from patients to better understand their challenges and perceived benefits of telemedicine. A qualitative study could be conducted to explore patient telemedicine experiences and develop patient resources and interventions to improve access to technology and better screen for and encourage patient eHealth literacy [135].
Healthcare professional perspective could also be further explored in future studies. Previous research shows that clinical experience and burnout are improved by training and a high technical knowledge and experience level [66]. As clinicians get more comfortable with virtual visits and new clinical support is added, provider experiences with telemedicine should be reassessed.
Lastly, more research could be conducted to understand the economic implications of healthcare provider reimbursement for virtual care and technology and operational aspects related to widespread virtual care deployment in clinical practice.
4.2 Limitations
A key limitation of this survey was the low response rate (21%). As reported in similar studies experiencing this can be attributable to the burden that healthcare providers faced during the pandemic [63]. The low response rate might have resulted in selection bias of study participants, leading to an overestimation of positive attitudes toward telemedicine, as healthcare professionals and managers with little interest in telemedicine might have been less likely to respond [136]. However, we compared answers from the two waves of respondents, and there was no significant difference.
Another limitation is related to the fact that the questionnaire used mainly closed-ended questions as these are perceived as easier to complete and help to optimise completion rates [137]. This could have led to the omission of some factors due to the limited options available to respondents. However, we believe this is unlikely as the survey design was driven by an extensive literature review and discussed with the study team, which includes healthcare staff and academics with health service delivery and telemedicine expertise. Closed-ended questions may restrict the respondents to the choices provided. Still, we do not believe this is the case because we added several open-ended questions allowing participants to expand on their responses and greater freedom of expression [138].
Finally, drivers, benefits and challenges have been analysed only from the provider's perspective, as patients were not included in the survey.