Review

Exploring Adult Patients’ Perceptions and Experiences of Telemedicine Consultations in Primary Care: A Qualitative Systematic Review

Jack Allen¹

doi: http://dx.doi.org/10.5195/ijms.2022.1363

Volume 10, Number 3: 288-315
Received 19 01 2022; Rev-request 05 03 2022; Rev-request 16 05 2022; Rev-recd 20 04 2022; Rev-recd 30 05 2022; Accepted 21 06 2022

ABSTRACT

The COVID-19 pandemic transformed a gradual uptake of telemedicine into a sudden worldwide implementation of telemedicine consultations. Primary care is a particular area affected and one where telemedicine consultations are expected to be the future. However, for effective long-term implementation, it is vital that patient perceptions and experiences are understood. The aim of this qualitative systematic review was to explore the perceptions and experiences of adults who have used telemedicine consultations in primary care. Studies were identified through a search of four electronic databases (MEDLINE, EMBASE, CINAHL, and CENTRAL) alongside reference list and citation searches. Quality assessment was conducted using the CASP checklist and data was synthesized using a simplified approach to thematic analysis. From 2492 identified records, ten studies met the eligibility criteria- all of which were judged as either good or moderate quality. Three themes were identified, which were potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations in primary care. Within these themes, sixteen sub-themes were identified with examples including accessibility and convenience for potential benefits, lack of face-to-face interaction and impersonal consultations for potential barriers, and continuity of care for beneficial prerequisites. Analyzing these sub-themes, four main recommendations for practice can be made that are: to utilize continuity of care, offer both video and telephone consultations, provide adequate support, and that healthcare professionals should demonstrate an explicit understanding of the patient's health issues. Further research is needed to explore and expand on this topic area and future research should be viewed as a continuous process.

Keywords: Telemedicine; Primary Health Care; General Practice; Qualitative Research (Source: MeSH-NLM).

Introduction

Telemedicine is a general term covering various forms of healthcare that are delivered remotely via telecommunication.^1,2 Since the term originated, various other terms such as telehealth, eHealth, and telecare have been used interchangeably within the literature.^1–4

The potential advantages of telemedicine for both patients and healthcare systems are vast and are well discussed throughout the literature.⁵ These potential advantages include increased access and reach of healthcare, convenience, and reduced costs.^6,7 Telemedicine does still have disadvantages such as difficulties developing a patient-physician relationship, technological obstacles, and inconsistencies with implementation.^8,9 Nevertheless, as these disadvantages are being addressed with various methods whilst advantages become more established, questions are moving beyond clinical and cost effectiveness of telemedicine into other areas such as patient perceptions.¹⁰

Over recent years, telemedicine use has been gradually increasing with benefits shown in a vast range of areas such as surgery, diabetes, and geriatrics.^3,7,11,12 Despite this, overall uptake has remained low.¹³ However, during the COVID-19 outbreak, face-to-face interaction had to be minimized, hence transforming this gradual uptake into sudden worldwide implementation of telemedicine.^14,15 Although this abrupt implementation affected all forms of telemedicine, some of the biggest changes to day-to-day practice were seen in telemedicine consultations, with these changes comprising of significant uptake rates, additional funding, and telemedicine becoming a fundamental component of healthcare rather than just an adjuvant.^16–19 Inadvertently, this unexpected mass implementation showcased the advantages of embedding telemedicine into healthcare on a large scale, particularly telemedicine consultations.^15,20

Primary care (PC) encompasses services which provide the first point of contact in a healthcare system, and it is a particular area in which telemedicine consultations are expected to be widely utilized in the future, with them anticipated to represent one of the biggest changes to working practices.^16,21 Telemedicine consultations in PC became standard practice during the pandemic. This is shown by the appointments which were face-to-face or via telemedicine consultations in General Practice in England changing from 79.6% and 14.46% respectively in December 2019, to 46.79% and 48.14% in April 2020, to 54.77% and 41.04% in April 2021.²² This trend of an abrupt increase followed by a slightly lower but sustained increase in telemedicine consultations in primary care was also seen in many countries such as the US, Australia, and Canada.^21,23,24 The acute increase in telemedicine is further demonstrated by telemedicine consultations in the US increasing from 1.1% in 2018-2019 to 35.3% in the second calendar quarter of 2020.²⁵ The view that telemedicine consultations are the future of PC was fairly well established before the pandemic, but it was greatly enhanced by the substantial benefits shown during the COVID-19 outbreak.^26,27 However, to effectively implement telemedicine into PC in the long term, certain areas such as patient perceptions need to be explored further.⁶

Patient satisfaction is a vital indicator of how healthcare is meeting patient expectations, acting as both an influential motivator and stressor to the development and improvement of healthcare services.^28,29 Additionally, continuous active involvement and engagement of patients in healthcare has been associated with improved outcomes and patient experiences, with patient participation in decision-making becoming a political necessity.^28,30,31 The importance of patient perceptions is further demonstrated by the key healthcare principle of person-centered care as to deliver person-centered care the patient perspective must be explored.³¹

Patient perceptions of telemedicine are typically assessed as patient satisfaction in the literature, which usually relates to quantitative assessment measures. However, patient perceptions and experiences are complex and are beyond any survey or predefined criteria.³² Additionally, many studies only assess patient perceptions as a secondary consideration. These factors often combine to result in superficial findings that only discuss the well-documented benefits rather than interviewing patients in-depth. Another concern is primary research often assesses clinician and patient perceptions together, resulting in some studies prioritizing the clinician's perceptions and neglecting detailed analysis of patient perceptions.³³

To assess current literature and the feasibility of a review, an initial scoping search was conducted. Common well-discussed aspects of telemedicine mentioned in studies were convenience, saving time, and a preference for face-to-face consultation.^34–41 Other important themes which are not as well acknowledged also arose, such as patient perceptions of the patient-physician relationship in telemedicine.^35,36,39 Although no comprehensive analysis was performed, the scoping search showed the literature was available to generate and explore themes to help better understand the patient perspective, which can then lead to recommendations for improving practice.

Several reviews have studied patient perceptions and experiences of telemedicine, and the consensus is: patient satisfaction is high for telemedicine, however, the number of reviews studying patient perceptions and experiences of telemedicine in PC is significantly less.^28,42,43 Reviews that relate to this topic area were assessed and multiple issues were identified. In several of these reviews, patient perceptions were not the main focus, with perceptions only being assessed quantitatively.^44,45 Thus, findings were minimal with analysis being superficial, consisting mostly of naming factors without thematic exploration. Further issues included reviews with narrow scopes meaning evidence was limited, therefore, narrative analysis of patient perceptions was also limited.⁴⁶ These issues highlighted a gap in the literature for a review which assess exclusively patient perceptions and experiences of telemedicine consultations in PC, utilizing qualitative research to explore perceptions in a greater depth.

This systematic review aims to explore the perceptions and experiences of adults who have used telemedicine consultations in a PC setting. To achieve this, key aspects that relate to the perceptions and experiences of adults who have used telemedicine consultations in a PC setting will be identified. Common themes for these perceptions and experiences will be generated using these key aspects, and finally the review will explore how the identification of these themes can be used to benefit future practice.

Methods

A comprehensive approach to searching was taken for this review with both the PRISMA and ENTREQ checklists being used throughout to improve reporting.^47,48 The review protocol and the checklists can be found in Appendices 1–3.

Eligibility Criteria

The SPIDER tool was utilized to develop the review question, eligibility criteria, and search strategy.⁴⁹

Sample: Studies were included if they assessed adults (18 years and older) in PC, whilst studies only assessing or focusing on children would be excluded.

Phenomenon of Interest: The phenomenon of interest was adjusted from any form of telemedicine in PC, to telemedicine consultations in PC in order to increase the review's feasibility whilst lowering the heterogeneity of included studies to facilitate thematic analysis. Studies were thus included if they were assessing telemedicine consultations in PC. The exclusion criteria included studies not based in PC, not primarily focused on telemedicine, and studies focused on telemedicine for a specific medical condition or for monitoring.

Design: Non-interventional qualitative or mixed-method studies of any theoretical framework were included.

Evaluation: Studies assessing patient perceptions and experiences of telemedicine consultations in a PC setting were included. If a study did not focus on patient perceptions or only focused on clinician's perspective, it was excluded. When both patient and physicians’ perceptions were assessed, results had to be clearly reported separately for inclusion.

Research type: Qualitative and mixed-method studies were included whilst purely quantitative studies were excluded. Mixed-method studies were however excluded if the qualitative aspect was minimal or there was a clear and significant imbalance in the weighting of the quantitative and qualitative aspects.

Information Sources

Four electronic databases were searched, which were MEDLINE via OvidSP (1946 to June 25, 2021), EMBASE via OvidSP (1974 to 2021 June 25), CINAHL via EBSCO (1981 to 2021), and CENTRAL (Issue 6 of 12, June 2021). Databases were last consulted on June 28, 2021. Reference list and citation searching (using Google scholar) was also conducted for all included studies. This consisted of all references and citations for each included study being screened against the eligibility criteria. All results from both searches were directly exported to the reference management software EndNote.⁵⁰

Search Strategy

The review question was preliminarily divided into the following concepts: telemedicine, PC, and perceptions/experiences. Scoping searches resulted in significant numbers of irrelevant results, so the concept of ‘perceptions/experiences’ was refined to ‘patient perceptions/experiences’ and the additional concept of qualitative research was added. After further scoping searches, free-text terms and relevant index terms/subject headings for each database were used alongside proximity searches to improve strategy effectiveness. The search strategy was trialed on each database and adjusted accordingly. The same search strategy was used for each database, and these can be found in Appendices 4–7.

Selection Process

Titles and abstracts were initially screened against the eligibility criteria, followed by full text screening.^51,52 Deduplication was done using the duplicate identification tool in EndNote then manually checked. If during this stage information was missing, the study authors would have been contacted and where there was no response, the studies would have been excluded and labelled as ‘potentially relevant’.⁵¹ As this review was conducted for a master's dissertation, study selection along with all other stages were conducted by a single reviewer, and this is a recognized limitation of the review.

Data Collection

Data was extracted from all study sections using a standardized data extraction form, developed by adapting a pre-existing form whilst using the Centre for Reviews and Dissemination guidelines.^51,53 The extraction form was then piloted and refined accordingly. Data extraction fields consisted of study details and context, participants, intervention, design/methods, findings, and other information. A complete list of the data items extracted can be found in Appendix 8. As with the other steps of this review, data extraction was conducted by a single reviewer and if data was missing the study authors would be contacted but as no missing data or inconsistencies were experienced, no authors were contacted.

Quality Assessment

To critically appraise the included studies, the CASP checklist for qualitative research was used.^54,55 The CASP checklist consists of ten major items which assess the studies according to the validity of results, what are the results, and how will the results help locally.⁵⁵ Studies were assessed against the sub-elements and then, these decisions were used to make a judgement of either ‘Yes’, ‘No’, or ‘Cannot tell’ for each major item.⁵⁵ Six major items from the CASP checklist (statement of aims, recruitment strategy, data collection, data analysis, statement of findings, and value of the research) were used to determine the overall quality assessment as outlined by Salmon⁵⁶.⁵⁵ This combined approach was taken as it produces a more simplified assessment whilst ensuring that the most important aspects for determining study quality are considered. The overall quality was determined as ‘good quality’ if all items were judged to be ‘Yes’, ‘moderate quality’ if one to two items were judged to be ‘No’ or ‘Cannot tell’, and ‘poor quality’ if three or more items were judged to be ‘No’ or ‘Cannot tell’. The quality assessment stage was conducted by a single reviewer due to the reason previously mentioned.

Data Synthesis

Data was synthesized using a simplified approach to thematic analysis as described by Aveyard,⁵⁴. Thematic analysis was chosen as it is a highly flexible approach, whilst being well suited to exploring the perspectives and developing new insights.⁵⁷ Aveyard's,⁵⁴ specific approach was used as it was developed considering aspects relevant to the review such as, limited resources, being conducted by a single reviewer, and not requiring expertise beyond a postgraduate level. The simplified thematic analysis consisted of summarizing article content with the use of tables, identifying themes, and then developing, naming, comparing, and scrutinizing these themes.⁵⁴ Data was coded line-by-line using an inductive approach with studies coded into pre-existing concepts and new concepts developed when required. Since data synthesis was conducted by a single reviewer, all steps were performed at least twice with frequent review to reduce this limitation. Due to limited resources, software programs were not used, but it was unlikely that this impacted the process. Subgroup and sensitivity analyses were not performed.

Ethics

As this is a systematic review, a student declaration alongside a risk assessment form signed by the reviewer and dissertation supervisor constitutes ethical approval as outlined by the University of Sheffield guidelines.

Results

Study Selection

The search strategy produced 1833 unique records which after initial screening of titles and abstracts left 23 records. Full-text screening of these records led to the identification of ten records for inclusion in this review. The breakdown of the study selection process can be seen in Figure 1 and the reasons for exclusion for the thirteen studies that reached full text screening can be found in Appendix 9.

Figure 1.

PRISMA Flowchart.

Study Characteristics

The main characteristics for included studies are presented in Table 1 and Table 2. As previously discussed, for the studies that were mixed-method studies, only the qualitative aspects of the study have been considered in this review.

Legend:

Legend:

Quality Assessment

Of the ten included studies, eight studies,^{34–36,58–62} were considered ‘good quality’ whilst the two remaining studies,^63,64 were considered ‘moderate quality’. One of the ‘moderate quality’ studies,⁶³ was judged to be of the lowest quality due to inadequate recruitment and data collection as it used retrospective data that was not collected for research purposes. The other ‘moderate quality’ study,⁶⁴ was judged as ‘unclear’ for data analysis as not enough information was provided. The results for all CASP checklist major items for each study are presented in Table 3. whilst a more detailed table which includes sub-elements is outlined in Appendix 10.

Legend: Yes = Y, No = N, Cannot tell = ?

Findings

Three overall themes were identified and developed which are potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations. Within these three themes, sixteen sub-themes were also identified. The results from individual studies can be found in Appendix 11 which is a table listing the existing themes from included studies. A table listing all the studies that contributed to each theme is outlined in Appendix 12.

Theme 1: Potential Benefits of Telemedicine Consultations Accessibility

Improved accessibility was a very common sub-theme that was identified in nine studies,^{34–36,58–62,64} with it being viewed as both an influencing and motivating factor for implementation of telemedicine consultations in PC. Another perception was that there was increased appointment availability which enabled a more prompt response whilst giving healthcare professionals (HCPs) more time to spend with patients. However, in one study,⁶² patients raised concerns about telemedicine consultations reducing accessibility for the elderly, especially if the system is not suitable for this demographic and becomes overused by younger patients. This is an important note for practice that if telemedicine consultations are ineffectively implemented, the potential benefit of improving access might not only be lost but result in reduced accessibility.

Equitable/Fair access

Moving beyond just improving accessibility, patients in three studies,^36,58,63 expressed views of telemedicine consultations creating more equitable access to PC. This was achieved by telemedicine consultations resulting in a fairer ability to access care for those finding face-to-face consultations difficult and at the same time, enabling clinicians to judge which patients require face-to-face consultations.

Convenience

Greater convenience was identified as a potential benefit in seven studies^{34–36,58,59,63,64}. Common aspects that improved convenience were: reduced travelling, saving time, and not missing work, with the latter even being described as potentially improving access for individuals with previously low engagement with healthcare.

Improved efficiency

The sub-theme of improved efficiency arose in five studies,^{35,36,58,59,63} with patients describing various ways they believed telemedicine consultations would make PC more efficient. Generally, all these points correlated to patients viewing telemedicine consultations as better use of resources and a way of preventing ineffective use such as removing unnecessary in-person appointments. The reason for removing unnecessary appointments links directly to the sub-theme of equitable access, as removing ‘timewasters’ was one of the ways patients perceived telemedicine consultations creating more equitable access. This helps to demonstrate how many of the identified sub-themes in this review are interlinked. Furthermore, improved efficiency due to telemedicine consultations has significant relevance to practice as it is a potential solution to the excessive demands on primary care which are thought to be negatively affecting the quality of care.^65,66

Lower threshold for seeking care

Telemedicine consultations lowering the threshold for seeking care was a sub-theme identified in four studies^34,59,63,64. Although this can be viewed as beneficial for patients, if the threshold becomes too low it could cause excess demand, negating the potential benefits. Thus, clear guidance should be available for its appropriate use.

Improved care for minor conditions or adjuvant to care

In four studies,^35,59,62,64 several points were made by patients about how rather than implementing telemedicine consultations for all consultations, a particular focus should be on minor conditions. Furthermore, patients from two studies,^36,61 described how telemedicine consultations should be an adjuvant to in-person care as the true benefits were as a supplement to face-to-face consultations and not as a replacement.

As with several of the other potential benefits, this sub-theme does not lead to a definitive recommendation for practice. However, the value of identifying the potential benefits is by recognizing, promoting and protecting them when developing telemedicine consultations for long-term implementation in PC.

Theme 2: Potential Barriers to Telemedicine Consultations Lack of face-to-face and physical interaction

A lack of face-to-face and physical interaction was one of the most common barriers with the sub-theme arising in nine studies^{34–36,58–61,63,64}. Concerns around not being seen in person or adequately examined were prevalent, with these in-person consultation aspects often giving patients reassurance that HCPs had conducted an effective assessment of health. Thus, these concerns represented a majority of the patients’ feelings with regards to the lack of face-to-face and physical interaction, and fearing that it would negatively affect care. Further worries included a loss of nonverbal communication and some patients describing difficulties discussing mental health issues without face-to-face interaction.⁵⁸ However, the effects of a lack of face-to-face interaction could be lowered by using video consultations rather than PC practices solely relying on telephone consultations as their only form of telemedicine.⁵⁹

Impersonal consultations

Heavily interlinked to the previous sub-theme, the potential barrier of impersonal consultations arose in seven studies,^{34–36,58–60,64} with patients describing telemedicine consultations as a less personal approach and a few reported feeling uncomfortable. Not all patients had this view- some patients found that telemedicine consultations were more focused and personal, although this was only reported by a minority of patients.³⁵ A further point for this sub-theme was several patients related impersonal consultations to not having an existing relationship with the HCP. Therefore, this barrier could be addressed by utilizing pre-existing relationships with continuity of care.

Difficulties with communication

Feelings of being unable to effectively communicate health issues when using telemedicine consultations were expressed by patients in five studies,^{35,58–60,63}. Certain patient groups were found to be particularly affected including the elderly, those with mental health issues, and patients with hearing impairments. In contrast, a few patients felt more comfortable communicating in telemedicine consultations as they felt more relaxed.^58,63

Technological concerns

Certain forms of telemedicine consultations, such as video consultations, may require a more advanced level of technological experience. Concern about this aspect was identified in six studies^{34–36,60,62,63}, which was mostly surrounding technological challenges the elderly may face when using telemedicine consultations that have a high demand on potential users. Further sub-theme development highlighted various ways to address this concern including providing a telephone consultation alternative to those with lower digital literacy and ensuring adequate support is available.⁶⁴

Confidentiality/Privacy concerns

Several patients across three studies,^35,36,58 expressed feelings of confidentiality being partly compromised when using telemedicine consultations. Most patients related this concern to not being able to achieve privacy at work, which meant they were reluctant to properly discuss their health issues, thereby making consultations ineffective.^35,36,59 A potential solution to this, and one suggested by patients during interviews, is for workplaces to have multifunctional private rooms in which telemedicine consultations could be conducted.

Concern of being overlooked

Patients in four studies,^58–60,63 described various concerns about being overlooked during telemedicine consultations as they felt the approach was intended to prevent patients from having face-to-face consultations. Therefore, to avoid patients feeling dismissed, HCPs need to demonstrate an understanding of the patients’ health issues and clearly explain why a face-to-face consultation is not required.

Difficulties with the uncertainty of consultation timings

Difficulty with the uncertainty of consultation timings, particularly considering work, was a small sub-theme only being identified in two studies,^58,63. However, this barrier can be overcome by methods such as more precise consultation timing periods.

Theme 3: Beneficial Prerequisites for Telemedicine Consultations Continuity of care

Telemedicine consultations being conducted by HCPs who have an existing relationship with the patient was described as a beneficial prerequisite in six studies,^{34–36,58,61,64}. Many patients believed having familiar HCPs was vital for communication during telemedicine consultations. This continuity of care as a prerequisite for telemedicine consultations can further be used to overcome several of the previously identified barriers, including the lack of face-to-face interaction, impersonal consultations, and communication difficulties. Two more relevant points which emerged for this sub-theme were the value of the importance of continuity of care to patients could vary depending on the medical complexity, and rapport could still be built if there was no previous relationship, but it was more difficult.^35,59

Provide support

The beneficial prerequisite of providing support was discussed by patients in three studies^35,61,62. Patients expressed worries about being excluded from PC services if adequate support is not provided. Additionally, this prerequisite can directly address technological concerns as a barrier to telemedicine consultations.

Clear process

Although only identified in two studies,^58,62 a prerequisite of having a clear process for telemedicine consultations was described as a critical aspect for successful implementation. A clear process involved having adequate and tailored information available to patients about how telemedicine consultations would function.

Discussion

Summary of Key findings

Six potential benefits of telemedicine consultations in PC were identified with many being interlinked. The two most prevalent benefits were improved accessibility and convenience, with the others being improved care for minor conditions, improved efficiency, a lower threshold for care, and a more equitable access. Additionally, an important finding was the concern that many of these potential benefits would be lost if the time is not taken to implement telemedicine consultations effectively.

A lack of face-to-face and physical interaction was the most prevalent barrier to telemedicine consultations in PC. Another important barrier was the impersonality of telemedicine consultations and was greatly linked to the previous barrier. Other barriers identified were difficulties with communication, technological concerns, confidentiality concerns, concerns of being overlooked, and uncertainty of consultation timings. Further development of each sub-theme led to potential ways to address each barrier.

The main beneficial prerequisite identified was having continuity of care for telemedicine consultations. This relates to patients having a pre-existing relationship with the HCP and can be used to overcome several of the previously identified barriers. The two other beneficial prerequisites were providing support and having a clear process.

Although it was thought that the COVID-19 pandemic may have lessened the severity of patient concerns of telemedicine, there was no observed difference in the pattern of how the two studies,^35,64 conducted around the COVID-19 pandemic contributed to benefits versus barrier compared to the other studies.⁵⁹

Comparisons with Previous Literature

No previous reviews have been conducted on patient perceptions and experiences of telemedicine consultations in PC using qualitative research. Despite this, some comparisons can be made between this review's findings and previous literature. Several sub-themes such as improved access, convenience, and patient concerns about a lack of face-to-face interaction, are also very prevalent in previous literature.^{10,28,37–42,46} However, these sub-themes are only mentioned rather than explored, an example of this is how one study reported only factor frequency, presenting findings such as 9% of articles stated ease of use as a benefit, without any further analysis.^10,28,42,46 Therefore, it is difficult to make any detailed comparisons. On the other hand, some sub-themes identified that are not as well acknowledged in previous literature were continuity of care, improved care for minor conditions, and patient concerns of being overlooked. Although not as well acknowledged, these factors were identified as very important aspects such as continuity of care being found to address many of the barriers identified.^35,36,67

Implications for Practice

Considering sub-themes alongside their prevalence in included studies and the strength of evidence, four main recommendations for practice can be made:

• PC services should utilize continuity of care for telemedicine consultations: telemedicine consultations should be conducted by HCPs with a pre-existing relationship with the patient to help reduce patient concerns for several identified barriers including the lack of face-to-face interaction, impersonality of consultations, and difficulties with communication.
• PC services should provide both telephone and video consultations rather than having only one available: video consultations help to address patient worries about the lack of face-to-face interaction, whereas phone consultations provide a lower digital literacy form of telemedicine consultations which helps to overcome potential technological concerns.
• PC services should have telemedicine support available for patients: this is to further address technological concerns and prevent patients from becoming excluded.
• When conducting telemedicine consultations, PC HCPs should make a conscious effort to show more of an understanding of the patient's health issues whilst giving clear reasons as to why a face-to-face consultation may not be required: if this is not done, patients feel dismissed and unsatisfied with telemedicine consultations.

Implications for Future Research

Although the review does not provide a comprehensive report of patients’ perceptions and experiences of telemedicine care in PC, it demonstrates important findings that are relevant to practice can be generated by studying this topic. Therefore, further research into patient perceptions and experience of telemedicine care in PC using qualitative research is not only required but should be seen as a continuous process.^28,29 The specific areas of focus for future research should include the benefits of telemedicine consultations that need to be protected, barriers that need to be addressed, and continuously evolving patient perceptions.

Limitations of the Review

A major limitation of this review was it being conducted by a single reviewer which affects all stages of the review, reducing the reliability whilst potentially introducing bias.^51,68 Limited resources, due to this review being for a postgraduate master's dissertation, contributed to further limitations. One of these limitations was that potential improvements to the search strategy that were identified such as grey literature searching, hand-searching, and contacting experts were not conducted.^51,69,70 Another limitation caused by the limited resources was the exclusion of non-English studies. In addition, not every sub-theme that was preliminarily identified in the initial stages of coding could be developed and explored, meaning that a few minor sub-themes are not included in this review.

Conclusion

The review explored patient perceptions and experiences of telemedicine consultations in PC using qualitative research. Three themes were identified: potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations in primary care. Within these themes, sixteen sub-themes were, identified with examples including accessibility and convenience for potential benefits, lack of face-to-face interaction and impersonal consultations for potential barriers, and continuity of care for beneficial prerequisites. Analyzing these subthemes, four main recommendations for practice can be made: to utilize continuity of care, offer both video and telephone consultations, provide adequate support, and that HCPs should demonstrate an explicit understanding of the patient's health issues.

Summary – Accelerating Translation

Title: Exploring Adults Patients’ Perceptions and Experiences of Telemedicine Consultations in Primary Care: A Qualitative Systematic Review Telemedicine is a general term covering various forms of healthcare that are delivered remotely via telecommunication. Despite the use of telemedicine gradually increasing over recent years with benefits shown in a vast range of areas, overall uptake remained low. However, during the COVID-19 outbreak, face-to-face interaction had to be minimized, thereby transforming this gradual uptake into sudden worldwide implementation of telemedicine consultations. Primary care is a particular area affected and one where telemedicine consultations are expected to be the future. Nonetheless, to effectively implement telemedicine into primary care in the long term, it is vital that patient perceptions and experiences are understood and explored.

Patient perceptions of telemedicine are typically assessed using quantitative measures even though patient perceptions and experiences are complex and beyond any survey or predefined criteria. Furthermore, they are often only assessed as a secondary consideration resulting in findings which are superficial. These issues highlighted a gap in the literature for a review, which assess exclusively patient perceptions and experiences of telemedicine consultations in primary care whilst using qualitative research to explore perceptions in a greater depth.

The aim of this systematic review is to explore the perceptions and experiences of adults who have used telemedicine consultations in a primary care setting using qualitative research.

Studies were identified through a search of four electronic databases (MEDLINE, EMBASE, CINAHL, and CENTRAL) alongside reference list and citation searches. Quality assessment for included studies was conducted using the CASP checklist which assess the studies according to the validity of results, what are the results, and how will the results help locally. Data was synthesized using a simplified approach to thematic analysis which consisted of summarizing article content with the use of tables, identifying themes, then developing, naming, comparing, and scrutinizing these themes.

From 2492 identified records, ten studies met the eligibility criteria all of which were judged as either good or moderate quality. Three themes were identified: potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations in primary care. Within these themes sixteen sub-themes were identified, with many interlinked. Six potential benefits of telemedicine were explored with the two most prevalent benefits being improved accessibility and convenience. Other potential benefits included improved care for minor conditions, improved efficiency, a lower threshold for care, and more equitable access. A lack of face-to-face and physical interaction was the most prevalent barrier to telemedicine consultations in primary care with the other potential barriers being impersonality of telemedicine consultations, difficulties with communication, technological concerns, confidentiality concerns, concerns of being overlooked, and uncertainty of consultation timings. The main beneficial prerequisite identified was having continuity of care for telemedicine consultations. This relates to patients having a pre-existing relationship with the healthcare professional, and can be used to overcome several of the previously identified barriers. The two other beneficial prerequisites were providing support and having a clear process.

Analyzing these subthemes, four main recommendations for practice can be made- to utilize continuity of care, offer both video and telephone consultations, provide adequate support, and that healthcare professionals should demonstrate an explicit understanding of the patient's health issues.

In conclusion, exploring patient perceptions and experiences of telemedicine consultations in primary care led to the identification of key benefits of telemedicine consultations that need to be promoted and protected, barriers that should be addressed for successful long-term implementation, and beneficial prerequisites for a better patient experience. All these aspects combine to produce valuable recommendations for practice with further research needed to explore and expand on this topic to ensure continuous improvement.

Acknowledgments

I would like to thank my supervisor Claire Beecroft for her continuous support and guidance throughout my dissertation and assistance in adapting it for publication.

Conflict of Interest Statement & Funding

The Authors have no funding, financial relationships or conflicts of interest to disclose.

Author Contributions

Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, and Writing – Review & Editing: JA.

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13. Holtz BE. Patients Perceptions of Telemedicine Visits Before and After the Coronavirus Disease 2019 Pandemic. Telemed E-Health. 2021;27(1):107–12.

14. Kannampallil T, Ma J. Digital Translucence: Adapting Telemedicine Delivery Post-COVID-19. Telemed E-Health. 2020;26(9):1120–2.

15. Leite H, Hodgkinson IR, Gruber T. New development: ‘Healing at a distance’—telemedicine and COVID-19. Public Money Manag. 2020;40(6):483–5.

16. Thornton J. Covid-19: how coronavirus will change the face of general practice forever. BMJ. 2020;m1279.

17. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ. 2020;m998.

18. Lovell T, Albritton J, Dalto J, Ledward C, Daines W. Virtual vs traditional care settings for low-acuity urgent conditions: An economic analysis of cost and utilization using claims data. J Telemed Telecare. 2021;27(1):59–65.

19. Fisk M, Livingstone A, Pit SW. Telehealth in the Context of COVID-19: Changing Perspectives in Australia, the United Kingdom, and the United States. J Med Internet Res. 2020;22(6):e19264.

20. Chiang C, Halker Singh R, Lalvani N, Shubin Stein K, Henscheid Lorenz D, Lay C, et al. Patient experience of telemedicine for headache care during the COVID?19 pandemic: An American Migraine Foundation survey study. Headache J Head Face Pain. 2021;61(5):734–9.

21. Jonnagaddala J, Godinho MA, Liaw ST. From telehealth to virtual primary care in Australia? A Rapid scoping review. Int J Med Inf. 2021;151:104470.

22. NHS Digital. Appointments in General Practice – Appointment Mode. 2022 Available from: https://app.powerbi.com/view?r=eyJrIjoiYzU2OTA2ODktZTIyNy00ODhmLTk1ZGEtOGVlZmRlZDNjYzY3IiwidCI6IjUwZjYwNzFmLWJiZmUtNDAxYS04ODAzLTY3Mzc0OGU2MjllMiIsImMiOjh9. Cited Apr 14, 2022.

23. Drake C, Lian T, Cameron B, Medynskaya K, Bosworth HB, Shah K. Understanding Telemedicine's “New Normal”: Variations in Telemedicine Use by Specialty Line and Patient Demographics. Telemed E-Health. 2022;28(1):51–9.

24. Liaw ST, Kuziemsky C, Schreiber R, Jonnagaddala J, Liyanage H, Chittalia A, et al. Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development. Yearb Med Inform. 2021;30(01):044–55.

25. Alexander GC, Tajanlangit M, Heyward J, Mansour O, Qato DM, Stafford RS. Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US. JAMA Netw Open. 2020;3(10):e2021476.

26. Bashshur RL, Howell JD, Krupinski EA, Harms KM, Bashshur N, Doarn CR. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed E-Health. 2016;22(5):342–75.

27. Daniel H, Sulmasy LS. Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper. Ann Intern Med. 2015;163(10):787.

28. Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017;7(8):e016242.

29. Cohen JB, Myckatyn TM, Brandt K. The Importance of Patient Satisfaction: A Blessing, a Curse, or Simply Irrelevant? Plast Reconstr Surg. 2017;139(1):257–61.

30. Vahdat S, Hamzehgardeshi L, Hessam S, Hamzehgardeshi Z. Patient Involvement in Health Care Decision Making: A Review. Iran Red Crescent Med J. 2014;16(1):e12454.

31. National Health System (NHS). NHS England » Involving people in their own care. NHS. Available from: https://www.england.nhs.uk/ourwork/patient-participation/. Cited Mar 6, 2021.

32. MacFarlane A, Harrison R, Wallace P. The Benefits of a Qualitative Approach to Telemedicine Research. J Telemed Telecare. 2002;8(2_suppl):56–7.

33. Peeters JM, Krijgsman JW, Brabers AE, Jong JDD, Friele RD. Use and Uptake of eHealth in General Practice: A Cross-Sectional Survey and Focus Group Study Among Health Care Users and General Practitioners. JMIR Med Inform. 2016;4(2):e11.

34. Bleyel C, Hoffmann M, Wensing M, Hartmann M, Friederich HC, Haun MW. Patients’ Perspective on Mental Health Specialist Video Consultations in Primary Care: Qualitative Preimplementation Study of Anticipated Benefits and Barriers. J Med Internet Res. 2020;22(4):e17330.

35. Imlach F, McKinlay E, Middleton L, Kennedy J, Pledger M, Russell L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract. 2020;21(1):269.

36. Powell RE, Henstenburg JM, Cooper G, Hollander JE, Rising KL. Patient Perceptions of Telehealth Primary Care Video Visits. Ann Fam Med. 2017;15(3):225–9.

37. Reed ME, Huang J, Parikh R, Millman A, Ballard DW, Barr I, et al. Patient-Provider Video Telemedicine Integrated With Clinical Care: Patient Experiences. Ann Intern Med. 2019;171(3):222–4.

38. Sevean P, Dampier S, Spadoni M, Strickland S, Pilatzke S. Patients and families experiences with video telehealth in rural/remote communities in Northern Canada. J Clin Nurs. 2009;18(18):2573–9.

39. West KS. Perceptions of Adult Patients Accessing Telehealth in an Urban Medical Group [Internet] [Doctor of Nursing Practice]. [San Jose, CA, USA, San Jose, CA, USA]: San Jose State University, Northern California Consortium, Doctor of Nursing Practice Program, California State University, Fresno and San José State University; 2019. Available from: https://scholarworks.sjsu.edu/etd_doctoral/93. Cited Mar 13, 2021.

40. Liaw WR, Jetty A, Coffman M, Petterson S, Moore MA, Sridhar G, et al. Disconnected: a survey of users and nonusers of telehealth and their use of primary care. J Am Med Inform Assoc. 2019;26(5):420–8.

41. Grubaugh AL, Cain GD, Elhai JD, Patrick SL, Frueh BC. Attitudes Toward Medical and Mental Health Care Delivered Via Telehealth Applications Among Rural and Urban Primary Care Patients. J Nerv Ment Dis. 2008;196(2):166–70.

42. Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ. 2000;320(7248):1517–20.

43. Williams TL, May CR, Esmail A. Limitations of Patient Satisfaction Studies in Telehealthcare: A Systematic Review of the Literature. Telemed J E Health. 2001;7(4):293–316.

44. Mold F, Hendy J, Lai YL, de Lusignan S. Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review. JMIR Med Inform. 2019;7(4):e13042.

45. Bunn F, Byrne G, Kendall S. The effects of telephone consultation and triage on healthcare use and patient satisfaction: a systematic review. Br J Gen Pract J R Coll Gen Pract. 2005;55(521):956–61.

46. Thiyagarajan A, Grant C, Griffiths F, Atherton H. Exploring patients’ and clinicians’ experiences of video consultations in primary care: a systematic scoping review. BJGP Open. 2020;4(1):bjgpopen20X101020.

47. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

48. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12(1):181.

49. Cooke A, Smith D, Booth A. Beyond PICO: The SPIDER Tool for Qualitative Evidence Synthesis. Qual Health Res. 2012;22(10):1435–43.

50. The EndNote Team. End Note. Philadelphia, PA: Clarivate; 2013.

51. Centre for Reviews and Dissemination, editor. CRD's guidance for undertaking reviews in healthcare. 3. ed. York: York Publ. Services; 2009. 281 p. (Systematic reviews).

52. Meline T. Selecting Studies for Systemic Review: Inclusion and Exclusion Criteria. Contemp Issues Commun Sci Disord. 2006;33(Spring):21–7.

53. Noyes J, Lewin S, Booth A, Hannes K, Harden A, Harris J, et al. Chapter 5: Extracting qualitative evidence. In: Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions [Internet]. 2011. Available from: http://cqrmg.cochrane.org/supplemental-handbook-guidance

54. Aveyard H. Doing a literature review in health and social care: a practical guide. Third edition. Maidenhead: McGraw-Hill Education, Open University Press; 2014. 190.

55. Critical Appraisal Skills Programme. CASP Qualitative Checklist [Internet]. 2018. Available from: https://casp-uk.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-2018_fillable_form.pdf. Cited Mar 8, 2021.

56. Salmon P. Assessing the quality of qualitative research. Patient Educ Couns. 2013;90(1):1–3.

57. Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. Int J Qual Methods. 2017;16(1):160940691773384.

58. Ball SL, Newbould J, Corbett J, Exley J, Pitchforth E, Roland M. Qualitative study of patient views on a ‘telephone-first’ approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments. BMJ Open. 2018;8(12):e026197.

59. Gabrielsson-Järhult F, Kjellström S, Josefsson KA. Telemedicine consultations with physicians in Swedish primary care: a mixed methods study of users’ experiences and care patterns. Scand J Prim Health Care. 2021;1–10.

60. Holmström IK, Nokkoudenmäki MB, Zukancic S, Sundler AJ. It is important that they care - older persons’ experiences of telephone advice nursing. J Clin Nurs. 2016;25(11–12):1644–53.

61. Lindberg J, Bhatt R, Ferm A. Older people and rural eHealth: perceptions of caring relations and their effects on engagement in digital primary health care. Scand J Caring Sci. 2021;scs.12953.

62. Nymberg VM, Bolmsjö BB, Wolff M, Calling S, Gerward S, Sandberg M. ‘Having to learn this so late in our lives…’ Swedish elderly patients’ beliefs, experiences, attitudes and expectations of e-health in primary health care. Scand J Prim Health Care. 2019;37(1):41–52.

63. Eccles A, Hopper M, Turk A, Atherton H. Patient use of an online triage platform: a mixed-methods retrospective exploration in UK primary care. Br J Gen Pract. 2019;69(682):e336–44.

64. Javanparast S, Roeger L, Kwok Y, Reed RL. The experience of Australian general practice patients at high risk of poor health outcomes with telehealth during the COVID-19 pandemic: a qualitative study. BMC Fam Pract. 2021;22(1):69.

65. Cowie J, Calveley E, Bowers G, Bowers J. Evaluation of a Digital Consultation and Self-Care Advice Tool in Primary Care: A Multi-Methods Study. Int J Environ Res Public Health. 2018;15(5):896.

66. Farr M, Banks J, Edwards HB, Northstone K, Bernard E, Salisbury C, et al. Implementing online consultations in primary care: a mixed-method evaluation extending normalisation process theory through service co-production. BMJ Open. 2018;8(3):e019966.

67. West K, Artinian B. Weighing options: Perceptions of adult patients accessing telehealth in primary care. Online J Nurs Inform. 2019;23(3).

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69. Aromataris E, Riitano D. Constructing a Search Strategy and Searching for Evidence. Am J Nurs. 2014;114(5):49–56.

70. Bramer WM, Rethlefsen ML, Kleijnen J, Franco OH. Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Syst Rev. 2017;6(1):245.

71. Atherton H, Pappas Y, Heneghan C, Murray E. Experiences of using email for general practice consultations: a qualitative study. Br J Gen Pract. 2013;63(616):e760–7.

72. Bulik RJ. Human factors in primary care telemedicine encounters. J Telemed Telecare. 2008;14(4):169–72.

73. Chang F, Paramsothy T, Roche M, Gupta NS. Patient, staff, and clinician perspectives on implementing electronic communications in an interdisciplinary rural family health practice. Prim Health Care Res Dev. 2017;18(02):149–60.

74. Donaghy E, Atherton H, Hammersley V, McNeilly H, Bikker A, Robbins L, et al. Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care. Br J Gen Pract. 2019;69(686):e586–94.

75. Hiratsuka V, Delafield R, Starks H, Ambrose AJ, Mau MM. Patient and provider perspectives on using telemedicine for chronic disease management among Native Hawaiian and Alaska Native people. Int J Circumpolar Health. 2013;72(1):21401.

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Protocol for Systematic Review: Exploring Adults’ Perceptions and Experiences of Telemedicine in Primary Care

Telemedicine is an umbrella term covering various forms of healthcare which is delivered remotely using telecommunication.^1,2 Other terms such as telehealth, eHealth, and mHealth are generally used interchangeably with telemedicine in the literature.^1,3 Potential advantages of telemedicine are well discussed throughout the literature, such as increasing the assess and reach of healthcare, improving convenience, and reducing cost.^4,5 With these factors around telemedicine becoming more established, questions are moving beyond the clinical and cost-effectiveness of telemedicine into other areas such as patient perceptions.⁶

Over recent years the use of telemedicine in healthcare has been gradually increasing with benefits shown in a vast range of areas including surgery, diabetes, and geriatrics.^2,4,7,8 However, during the COVID-19 outbreak face-to-face consultations had to be avoided, causing this gradual uptake to become a sudden worldwide implementation of telemedicine to help manage the pandemic.^9,10 Inadvertently, this unexpected mass implementation has showcased the advantages of embedding telemedicine into healthcare on a large scale.⁹

Primary care is a particular area in which telemedicine is expected to be widely utilized in the future, and this view was further enhanced by the substantial benefits shown during the COVID-19 pandemic.^11,12 However, in order to effectively implement telemedicine into primary care in the long-term, certain areas need to be explored further. One of the areas that will be vital to the effective implementation of telemedicine is understanding patient perceptions and experiences.⁵

Patient satisfaction acts as both an influential motivator and stressor to the development and improvement of healthcare services.¹³ Additionally, active involvement and engagement of patients in healthcare has been associated with improved outcomes and patient experiences.^14,15 The importance of patient perceptions are further demonstrated by the key NHS and general healthcare principle of person-centered care, as to deliver person-centered care the patient perspective must be explored.¹⁵

Although there is literature on patient perceptions of telemedicine generally, there is a gap in the literature regarding a review of the patient perceptions specifically surrounding telemedicine in primary care. Various primary research has been produced on this topic generating several themes, however, this information has not yet been brought together in a review. The current literature around patient perceptions of telemedicine and primary care will be discussed further in the literature review section.

Summarizing the previous points, the use of telemedicine in primary care is continuously increasing and the focus for telemedicine research is moving beyond clinical and cost-effectiveness. Furthermore, these points combined with the importance of understanding patient perceptions in healthcare, demonstrate the rationale behind a review exploring patient perception of telemedicine specifically relating to primary care.

What are the perceptions and experiences of adult patients who have used telemedicine in primary care?

Aim

• To explore the perceptions and experiences of adults who have used telemedicine in a primary care setting.

Objectives

• Identify key aspects that relate to the perceptions and experiences of adults who have used telemedicine in a primary care setting
• Generate common themes for the perceptions and experiences of adults who have used telemedicine in a primary care setting
• Explore how the identification of these themes can be used to benefit future practice

Patient satisfaction of telemedicine usually relates to quantitative measures of assessing patient perceptions of telemedicine, and there is various literature exploring this. The consensus of the literature is that patients are satisfied with telemedicine with consideration to various parameters such as access and convenience.^5,16 However, for this systematic review the focus is to explore beyond if patients are satisfied, but to try to understand the themes behind patient perceptions of telemedicine, specifically primary care.

Various telemedicine studies include aspects assessing patient perceptions, but this is often not the focus of the study and is a secondary consideration. As a result, the findings tend to be superficial, and only discuss the well documented benefits to patients rather than interviewing patients in-depth. In order to assess what literature has been published and the feasibility of a systematic review on patient perceptions of telemedicine in primary care, a scoping search was performed.

For this scoping search the CINAHL database was used, and the search terms can be seen in the appendix. After reviewing the titles and abstracts for suitable studies that focused on patient perception of telemedicine in primary care, the 748 articles were reduced to 18. Various methods were used by the studies with nine using qualitative methods,^17–25 seven using quantitative methods,^26–32 and two being mixed method studies,^33,34. The different studies resulted in a variety of conclusions but there were some key themes that arose.

Common, well-discussed aspects of telemedicine were mentioned in numerous studies such as convenience,^{21,22,24,25,32,34} saving time,^{21,22,24,27,32,34} and a preference to be seen face-to-face,^24,26,34. One theme which is not as well acknowledged currently in the literature is patient perceptions of the patient physician relationship in telemedicine. This transpersonal relationship is an important aspect to a positive experience of telemedicine for patients,^21,25,34. It was easier if this relationship was pre-existing, but it could be developed without a prior relationship before the telemedicine consultation.³⁴ The relevance of this to practice is that consideration and effort needs to be made for developing this patient physician relationship in order to deliver telemedicine in an effective way, whilst enhancing the patient experience.

Another theme that arose from multiple articles was patients expressing a need for telemedicine in primary care to be tailored to the individual or group,^{17,18,20,22,33}. A user-centered design approach should be taken as trying to use telemedicine without consideration to specific context would cause negative patient attitudes and experiences.²⁰

Although this is only a scoping search, so no comprehensive analysis of the themes has been done, it demonstrates that addressing the gap in the current literature of a review surrounding patient perceptions of telemedicine in primary care would be of benefit, as bringing the current literature together will produce findings which can help to better understand the patient perspective. Both of the themes disused along with others such as a concern for telemedicine not being effectively integrated with other aspects of healthcare,^17,20,22,27 would be explored in further detail in the systematic review.

As the focus of this review is exploring the perceptions and experiences of patients, literature using the qualitative interpretivism approach is more appropriate than the quantitative positivist approach.³⁵ This was confirmed by the scoping search with qualitative studies exploring this area in significantly more depth than quantitative studies. Considering this, the SPIDER acronym was used to help guide development of a focused research question as it was specifically developed for qualitative research questions.³⁶

Question: What are the perceptions and experiences of adult patients who have used telemedicine in primary care?

Sample: Adult patients in primary care.

Phenomena of Interest: Use of any form of telemedicine in primary care.

Design: Non-interventional qualitative or mixed method studies of any theoretical framework.

Evaluation: Perceptions and experiences of telemedicine in primary care.

Research: Qualitative or mixed method research.

Both MeSH and free-text terms will be used alongside Boolean operators to search the electronic databases.³⁷ Below are the MeSH and free-text terms which will be used.

Multiple electronic databases will be searched including CINAHL, MEDLINE, EMBASE, and Cochrane Library. To further ensure all relevant articles are identified, both examination of reference lists and citation searching using Google scholar will be conducted.³⁸

As previously mentioned, qualitative studies will be used in this systematic review and thus a qualitative systematic review methodology will be utilized.³⁹ Due to the scoping search demonstrating a potentially limited number of primary studies that are purely qualitative studies on the topic, suitable mixed-method studies will also be included in this systematic review.

Inclusion and exclusion criteria have been created using the SPIDER acronym with the addition of language and can be seen below in the table.³⁶

Study selection will consist of two stages; initially the titles and abstracts will be screened against the inclusion criteria to identify potentially relevant studies.⁴⁰ Duplicates will be removed and in cases where information is missing the study authors will be contacted, if this is not feasible the studies will be excluded and labelled as ‘potentially relevant studies’.⁴⁰ In the next step, studies that appear to meet the inclusion criteria or studies where further assessment is required, will be screened using the full papers. To document and report this process in a complete and transparent manner a PRISMA flow diagram will be used alongside a table showing the characteristics of excluded studies with reasons for exclusion.^37,41 All of this processing will be completed by one reviewer, and this is a recognized limitation of the study.

To critical appraise included studies the Critical Appraisal Skills Programme (CASP) checklist for qualitative research will be used.^37,42 The CASP checklist consists of 10 questions which aim to help systematically assess the studies according to the three broad issues of validity of results, what are the results, and how will the results help locally.⁴²

Data will be extracted using a standardized data extraction form to provide consistency to the review whilst reducing bias, but also improving validity and reliability.⁴⁰ The standardized data extraction form will be created by adapting a pre-existing form such as one outlined by Noyes et al.,⁴³. The Centre of Reviews and Dissemination (CRD) guidelines will also help in this process.⁴⁰ To ensure all relevant information will be captured, the data extraction form will be piloted on a small sample of studies and then refined accordingly.⁴⁰ The data extraction form will be electronic to allow for the combination of data extraction and data entry in the same step, whilst also facilitating the data analysis.⁴⁰ As with all other steps in this review, data extraction will be conducted by a single reviewer and where data is missing study authors will be contacted. An example of some of the data extraction fields and information that will be extracted can be seen in the appendix.

Data will be synthesized using a simplified approach to thematic analysis as described by Aveyard,³⁷. This approach was developed by taking ideas from previous thematic analysis work in combination with feedback and experience to refine and amend the approach technique. The stages of the simplified thematic analysis that will be used for this review consist of summarizing the content of all articles with the use of tables, identifying themes, developing and naming these themes, comparing themes, and scrutinizing the themes. A simplified approach to thematic analysis as outlined by Aveyard,³⁷ was chosen over other approaches because it was developed to be well suited for use by undergraduate and postgraduate students. This was achieved by considering aspects relevant to single student projects such as limited resources, the review being conducted by only a single reviewer, and not requiring a level of expertise which is beyond postgraduate level.³⁷

Below is a preliminary timetable for the review with milestones to monitor progress.

Protocol References

1. Wootton R. Recent advances: Telemedicine. BMJ. 2001 Sep 8;323(7312):557–60. Available from doi: http://dx.doi.org/10.1136/bmj.323.7312.557

2. Asiri A, AlBishi S, AlMadani W, ElMetwally A, Househ M. The Use of Telemedicine in Surgical Care: a Systematic Review. Acta Inform Medica. 2018;26(2):201. Available from doi: http://dx.doi.org/10.5455/aim.2018.26.201-206

3. World Health Organization, editor. Telemedicine: opportunities and developments in member states: report on the second Global survey on eHealth. Geneva, Switzerland: World Health Organization; 2010. 93 p. (Global observatory for eHealth series). Available from ISBN: 978-92-4-156414-4

4. Dorsey ER, Topol EJ. State of Telehealth. Campion EW, editor. N Engl J Med. 2016 Jul 14;375(2):154–61. Available from doi: http://dx.doi.org/10.1056/NEJMra1601705

5. School of Health Sciences Mamba’ul ’Ulum, Surakarta, Atmojo JT, Sudaryanto WT, Study Program in Physiotherapy, Universitas Muhammadiyah Surakarta, Widiyanto A, School of Health Sciences Mamba’ul ’Ulum, Surakarta, et al. Telemedicine, Cost Effectiveness, and Patients Satisfaction: A Systematic Review. J Health Policy Manag. 2020;5(2):103–7. Available from doi: http://dx.doi.org/10.26911/thejhpm.2020.05.02.02

6. Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: A systematic review of reviews. Int J Med Inf. 2010 Nov;79(11):736–71. Available from doi: http://dx.doi.org/10.1016/j.ijmedinf.2010.08.006

7. Batsis JA, DiMilia PR, Seo LM, Fortuna KL, Kennedy MA, Blunt HB, et al. Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review. J Am Geriatr Soc. 2019 Aug;67(8):1737–49. Available from doi: http://dx.doi.org/10.1111/jgs.15959

8. Lee JY, Lee SWH. Telemedicine Cost–Effectiveness for Diabetes Management: A Systematic Review. Diabetes Technol Ther. 2018 Jul;20(7):492–500. Available from doi: http://dx.doi.org/10.1089/dia.2018.0098

9. Leite H, Hodgkinson IR, Gruber T. New development: ‘Healing at a distance’—telemedicine and COVID-19. Public Money Manag. 2020 Aug 17;40(6):483–5. Available from doi: http://dx.doi.org/10.1080/09540962.2020.1748855

10. Kannampallil T, Ma J. Digital Translucence: Adapting Telemedicine Delivery Post-COVID-19. Telemed E-Health. 2020 Sep 1;26(9):1120–2. Available from doi: http://dx.doi.org/10.1089/tmj.2020.0158

11. Daniel H, Sulmasy LS. Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper. Ann Intern Med. 2015 Nov 17;163(10):787. Available from doi: http://dx.doi.org/10.7326/M15-0498

12. Bashshur RL, Howell JD, Krupinski EA, Harms KM, Bashshur N, Doarn CR. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed E-Health. 2016 May;22(5):342–75. Available from doi: http://dx.doi.org/10.1089/tmj.2016.0045

13. Cohen JB, Myckatyn TM, Brandt K. The Importance of Patient Satisfaction: A Blessing, a Curse, or Simply Irrelevant? Plast Reconstr Surg. 2017 Jan;139(1):257–61. Available from doi: http://dx.doi.org/10.1097/PRS.0000000000002848

14. Vahdat S, Hamzehgardeshi L, Hessam S, Hamzehgardeshi Z. Patient Involvement in Health Care Decision Making: A Review. Iran Red Crescent Med J [Internet]. 2014 Jan 5 [cited 2021 Mar 13];16(1). Available from: https://sites.kowsarpub.com/ircmj/articles/16044.html

15. NHS. NHS England ” Involving people in their own care [Internet]. NHS. [cited 2021 Mar 6]. Available from: https://www.england.nhs.uk/ourwork/patient-participation/

16. Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017 Aug;7(8):e016242. Available from doi: http://dx.doi.org/10.1136/bmjopen-2017-016242

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Protocol Appendix 1:

Screenshot of search terms used in the scoping search strategy

Jack Allen, 1 Master of Public Health (MPH) and Final-year Medical Student. University of Sheffield, Sheffield, UK.

About the Author: Jack Allen is a fifth-year medical student at the University of Sheffield Medical School, Sheffield, England. In between third and fourth year of medical school he completed a Masters in Public Health (Management and Leadership) being awarded a distinction and this research was produced as part of his masters dissertation.

Correspondence: Jack Allen. Address: University of Sheffield, Beech Hill Rd, Broomhall, Sheffield S10 2RX, UK. Email: jtallen1@sheffield.ac.uk

Editor: Vincent Kipkorir Student Editors: Leah Komer, Duha Shellah, & Moez Bashir. Copyeditor: Madeleine J. Cox Proofreader: Madeleine J. Cox Layout Editor: Ana Maria Morales Process: Peer-reviewed

Cite as: Allen J. Exploring Adults Patients' Perceptions and Experiences of Telemedicine Consultations in Primary Care: A Qualitative Systematic Review. Int J Med Stud. 2022 Jul-Sep;10(3):288-315.

Copyright © 2022 Jack Allen

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 10, NUMBER 3, August 2022