Associations of clinical personnel characteristics and telemedicine practices

Data source

We utilized the 2021 NEHRS dataset to perform a cross-sectional study to determine the relationship between physician characteristics and telemedicine practices. The NEHRS is a national survey conducted by the National Center for Health Statistics (NCHS) and sponsored by the Office of the National Coordinator for Health Information Technology (ONC) of office-based physicians in the United States conducted annually utilizing web, mail, and telephone [19]. Because all NEHRS data undergo the removal of personal identifiers prior to being released to the public [20] our study did not require Institutional Review Board (IRB) approval. The NEHRS is utilized to estimate the adoption of state and national Electronic Health Records (EHRs), EHR capabilities, and burden associated with EHRs [19]. Data collected through the NEHRS are utilized by the NCHS to publish reports and web tables to detail EHR adoption [19]. The NEHRS obtained telemedicine practice data from 1,875 physicians in 2021 [21].

Eligibility

Because the purpose of this study was to assess differences in telemedicine practices of physicians and their demographics, respondents were included if they answered the following three questions. The first question was: “Does your practice utilize telemedicine technology for patient visits?,” with the responses being “Yes,” “No,” and “Don’t know.” The second question was: “Since March 2020, what percentage of your patient visits were through telemedicine technology?” Responses for this question were “None,” “Less than 25 %,” “25–49 %,” “50–74 %,” “75 % or more,” and “Don’t know.” Finally, the last question was “What type(s) of telemedicine tools did you utilize for patient visits?” This question had five response options: (1) “Telephone audio”; (2) “Videoconference software with audio (e.g., Zoom, Webex, FaceTime)”; (3) “Telemedicine platform NOT integrated with EHR (e.g., Doxy. me)”; (4) “Telemedicine platform integrated with EHR (e.g., update clinical documentation during telemedicine visit)”; and (5) “Other tool(s).” Responses of “Don’t know” or that were missing were excluded from analysis.

Demographic measures

Physician demographics characteristics extracted from NEHRS included physician age (under 35, 35–44, 45–54, 55–64, or 65 and above), sex (male or female), field (primary care, surgical, medical), and type of training (DO or MD). Primary care specialty includes physicians reporting as family medicine, internal medicine, pediatrics, and obstetrics. Examples of surgical specialties include general surgery, plastic surgery, and otolaryngology. Medical specialties included addiction medicine, gastroenterology, and nephrology, among many others. All responses reported as “blank” or “not applicable” were excluded from the analysis.

Statistical analysis

For each analysis, we applied the survey design and weighting provided by NEHRS. First, we reported the number of physicians in the sample (n), the national estimate (N), and the weighted percentages for physician characteristics such as age, sex, specialty, and training. Then we reported the national prevalence of telemedicine practices among all doctors for the year 2021. Next, utilizing design-based chi-square tests, we determined the associations between telemedicine practices and physicians’ sex, age, specialty, and training. Statistical analysis was conducted in Stata 16.1 (StataCorp LLC, College Station, TX). Alpha was set at 0.05 for all analyses.

Study demographics

Our analysis of the NEHRS included 1,866 physicians responding to questions regarding telemedicine use during the 2021 cycle. Of these physicians, 1,257 (67.9 %) were males and 609 were females (32.1 %; Table 1). Physicians over age 50 accounted for 1,215 responses (67.6 %), and physicians under age 50 accounted for 621 responses (32.4 %) equals 1,836. However, the total number of physicians who responded was 1,866. Regarding medical specialties, primary care physicians accounted for the most responses, with 909 responses (45.9 %), followed by medical specialty physicians with 547 responses (33.0 %) and surgical specialty physicians with 410 responses (21.1 %). Finally, allopathic (MD) physicians accounted for 1,739 responses (94.3 %), while osteopathic (DO) physicians accounted for 127 responses (5.7 %).

Primary outcome

Among the sample (Table 1), 91.9 % of female physicians utilized telemedicine services in practice, and 84.7 % of male physicians utilized telemedicine services in practice; this comparison was statistically significant (X ²=8.0; p=0.005). Ninety-one percent of physicians under age 50 utilized telemedicine services in practice, and 85.1 % of physicians over age 50 utilized telemedicine services in practice. This comparison was also statistically significant (X ²=4.1; p=0.04). Another statistically significant difference exists between the specialty category and the use of telemedicine services in practice (X ²=11.5; p<0.001). Among those in primary care, 91.7 % utilized telemedicine services in practice, compared to 75 % in the surgical specialty and 88.2 % in medical specialties. There was no significant difference in type of degree (Allopathic physicians compared to Osteopathic physicians) and the use of telemedicine services in practice (X ²=0.4; p=0.52).

There was no statistically significant difference between female physicians and male physicians and the percentage of patients seen via telemedicine services (Table 2) (X ²=1.52; p=0.21). There was also no statistically significant difference between physicians under age 50 and over age 50 and the percentage of patients seen via telemedicine services (X ²=0.2; p=0.88). However, a statistically significant difference exists between the specialty category and the percentage of patients seen via telemedicine services (X ²=9.4; p<0.001), with primary care physicians seeing an average of 48.4 % (n=830) of patients via telemedicine and surgical specialties seeing only 18.1 % (n=292) of patients utilizing telemedicine. Further, 66.7 % (n=333) of physicians in medical specialties saw between 1 and 50 % of their patients through telemedicine services, whereas 27.5 % (n=130) saw more than 50 % of their patients via telemedicine services. There was no significant difference in the type of degree (Allopathic physicians compared to Osteopathic physicians) and the percentage of patients seen via telemedicine services (X ²=1.6; p=0.19).

Secondary outcome

There were no statistically significant differences in the type of telemedicine tools utilized in practice between male and female physicians (Table 3) (X ²=0.4; p=0.73), physicians under age 50 and over age 50 (X ²=1.73; p=0.17), specialty category (X ²=1.7; p=0.13), or type of degree (Allopathic physicians compared to Osteopathic physicians) (X ²=0.4; p=0.81).

Male and female physicians

We found that female physicians are more likely than male physicians to utilize telemedicine services in practice. Similarly, a study published in 2022 found that female physicians reported a higher use of telephone consultations, higher assessment of telemedicine, and higher portion of patient contact with telemedicine than male physicians [24]. This difference in telemedicine use between male and female physicians may be explained by the different communication styles of men and women [24]. For example, female physicians tend to be more aligned with developing interpersonal relationships than do male physicians [25]. Further, female physicians tend to be more inclined to engage in both patient involvement and partnership development than do male physicians [26, 27]. Gender differences within the specialties may also explain this difference in telemedicine use. For example, the 2020 Physician Specialty Data Report showed that surgical specialties are overwhelmingly composed of male physicians [28]. Given that the specialty category least likely to participate in telemedicine services in our study was the surgical specialty, this inherent difference between the number of male and female surgeons may have contributed to our findings.

Physician age

Studies examining the use of telemedicine services by age group also found similar results – with younger physicians more likely to adopt telemedicine technology. Nies et al. [29] conducted a cross-sectional study to assess the utility of telemedicine among patients attending a primary care practice in a federally qualified health center (FQHC) in New York. They found that providers who reported that they would utilize telemedicine in the future were younger, with a mean age of 44 [29]. Because patients increasingly rely on telemedicine services to access care, identifying barriers to the use of telehealth among older physicians and creating specific solutions to address those barriers may increase patient access to care. Additionally, as the population continues to age, simplified methods for utilizing telehealth services, such as reviewing technology basics and utilizing audio only or phone-based [30] options, might provide solutions for individuals who are less comfortable utilizing technology.

Physician specialty

Finally, our findings also revealed that physician specialty is significantly associated with the overall use of telemedicine services and the percentage of patients seen via telemedicine services. Our study found that primary care physicians participate in telemedicine services the most, with 91.7 % of physicians in the primary care category responding “yes” to participation in telemedicine, as compared to 88.2 % for medical specialties and 75 % for surgical specialties. This shows a significant increase in the percentage of physicians utilizing telemedicine compared to 2014. A 2017 study showed that approximately 15 % of family medicine practitioners utilized telemedicine services in 2014 [17]. A large portion of the difference in the percentage of primary care specialties utilizing telemedicine compared to the surgical and medical specialties can likely be attributed to the practice setting. Medical and surgical specialties often encounter patients in medical facilities due to more severe conditions requiring more advanced care than primary care specialties managing less serious health risks. Further, surgical specialty office visits more commonly necessitate a physical examination – whether to determine a need for surgery or for direct postoperative wound care – which likely discourages telemedicine use for surgical specialists.

Interestingly, advanced technology that allows for a ‘virtual’ physical examination has also been reported [31]. Digital stethoscopes that can record, analyze, and send heart sounds to clinicians have been developed for cardiovascular examinations [31]. For gastrointestinal examinations, single-axis accelerometers, when paired with smartphone apps, allow patients to engage in self-palpation, compared with physician palpation, and then provide feedback on how to match physician palpation: more or less depth and shorter or longer compression [31]. While these technological advances may one day allow for an improved virtual examination for many patients [31], and thus increased telemedicine use by more physicians, this technology is not yet widely available for clinicians to utilize in telehealth.

Insurance reimbursement is another factor that may influence telemedicine use, regardless of the physician’s specialty. A 2019 study of virtual vascular surgeon visits showed the economic potential of telemedicine, with insurance reimbursements of up to 67 % of the total charges billed [32]. Another study in 2019 found that the top three specialists who utilized telemedicine services were radiologists, psychiatrists, and cardiologists. The study also showed that the three specialties that utilized telemedicine the least were allergists/immunologists, gastroenterologists, and obstetrics-gynecologists [33]. In the future, we will likely see more of an increase in telemedicine usage by all specialties as technology advances to meet their particular needs for remote patient evaluation and diagnostics.

Recommendations

Overall, our results indicate high rates of telemedicine usage among physicians – especially those in family medicine – regardless of the type of medical training, which aligns with many current patients’ preferences for telemedicine services. Ensuring access to these telemedicine services enables physicians to become more accessible and, in effect, provide care to a broader range of patients. Expanding the availability of high-speed internet and Wi-Fi access in rural areas is also needed to broaden telemedicine access, which has been reported as a barrier to telehealth intervention [34]. However, these limitations to internet access in rural regions have been reported at rates much lower than common conceptions, which shows that telehealth technology can be successfully implemented in rural areas [34]. As previously mentioned, simplifying telehealth technology [30] tailoring options available to physicians, and providing training may help physicians who are male or over the age of 50 more frequently engage patients through telemedicine. This, in turn, may also increase services provided to rural areas [35] federally designated health professional shortage areas, and medically underserved populations that rely on telehealth services as a means for accessing care [36]. Further, for physicians to adopt telemedicine more widely, more significant development and accessibility of advanced telehealth modalities that allow for improved virtual examinations and thus increased confidence in clinical decision-making, are needed.

Strengths and limitations

A strength of this study is that the dataset provided a large enough sample size that allowed for sufficient statistical strength of data analysis. Regarding limitations, because the study design was cross-sectional, it is difficult to determine causal inference. However, the choice of study design was appropriate because cross-sectional studies help determine multiple associations efficiently. Self-report biases posed another limitation. Further, the NEHRS does not provide information regarding the general practice location (e.g., urban vs. rural) of physicians who utilize telemedicine services. Future studies should examine this pattern of physician telemedicine usage and practice location to identify possible associations. Additionally, studies assessing trends in the use of telemedicine during the COVID-19 pandemic might highlight changes in the use of telemedicine mediated by the pandemic and showcase barriers that continue to exist in implementing a broader use of telemedicine services. Nevertheless, this study underscores multiple physician characteristics associated with telemedicine use in practice. Ongoing efforts should focus on further investigating the characteristics of physicians who utilize telemedicine services in practice – potentially conducting qualitative research on physician reasoning for utilizing or, more importantly, not utilizing telemedicine services.