Clinician Telemedicine Perceptions During the COVID-19 Pandemic
Harrison Miner, BA,1 Amirreza Fatehi, MD,1
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additional study. Early implementation of telemedicine might
David Ring, MD, PhD,1 and Jason S. Reichenberg, MD, MBA2
1
Department of Surgery and Perioperative Care, Dell Medical
School, University of Texas at Austin, Austin, Texas, USA.
2
Department of Internal Medicine, Dell Medical School, University
of Texas at Austin, Austin, Texas, USA.
T
Abstract
Background: Telemedicine utilization increased exponen-
tially due to the coronavirus disease 2019 (COVID-19) pan-
demic. As a result, most clinicians now have experience with
telemedicine.
Questions/Purposes: We studied factors independently associ-
ated with a clinician desiring to continue telemedicine services
after the COVID-19 pandemic. Secondarily, we sought factors
independently associated with clinician satisfaction with the
quality of care provided through telemedicine and factors as-
sociated with telemedicine platform preference by clinicians.
Methods: A large multispecialty medical group of physicians
were invited to complete a survey, including demographics,
telemedicine experience, satisfaction with various elements of
telemedicine encounters, desired features in a telemedicine
platform, personality traits, and preferences. A total of 220
complete responses were analyzed.
Results: A desire to continue offering telemedicine visits after
the COVID-19 pandemic was independently associated with a
higher satisfaction with the quality of telemedicine care, en-
dorsement of the ease of performing a physical examination
with telemedicine, belief that adaptability is an important
element of being a clinician, and less preference for in-person
work meetings over virtual meetings. Higher satisfaction with
the quality of telemedicine care was associated with belief
that adaptability is an important element of being a clinician,
clinicians who identify as being more perceiving (value flex-
ibility) than judging (value organization), providers from
relatively urban counties, and those with less preference for
in-person work meetings over virtual meetings. Clinicians
ranked ease of use for patients and physicians as the most
important features of telemedicine platforms.
Conclusions: The observed association of clinician person-
ality and interpersonal preferences with the appeal, satis-
faction, and perceived effectiveness of telemedicine merit
DOI: 10.1089/tmj.2020.0295 ª M A R Y A N N L I E B E R T , I N C .  VOL. 00
be easiest with clinicians that take pride in their adaptability
and value a technology-based workstyle.
Keywords: telemedicine, telehealth, virtual visit, COVID-19,
physician satisfaction
Introduction
elemedicine is medical care provided remotely using
technology. There is a growing interest in tele-
medicine because of its convenience, accessibility,
and lower costs. Cost analyses suggest that virtual
visits can cost less than in-person encounters. Two studies
estimated a very low threshold (80–151 patients a year1,2) to
reach a point where telemedicine was more cost-effective
than in-person visits in specialty orthopedic care with
45% less cost per patient.3 Telemedicine is associated with
satisfactory ratings by patients and clinicians4–8 and patient–
physician communication is comparable with in-person visits.9
Clinician concerns about technical hurdles (training and im-
plementation), legal and ethical rules such as lack of interstate
licensure reciprocity, concerns about maintaining patient
confidentiality, concerns about limited precedent regarding
liability issues, lack of widespread reimbursement, and lack of
universal accessibility have limited adoption of telemedicine to
date. Yet the potential benefits of telemedicine include im-
proved access, more equitable care, and lower costs.10–15 Ad-
ditionally, advances in technology and access to smart phones
and internet access have made telemedicine more accessible.
The coronavirus disease 2019 (COVID-19) pandemic led to a
rapid expansion in telehealth worldwide. As a result, the
majority of clinicians have had experienced using tele-
medicine on a variety of platforms. This experience may have
changed their views of telemedicine, and it may become more
utilized even after the pandemic is over.
The primary purpose of this study was to determine if
there are any factors independently associated with a clinician
desiring to continue telemedicine services after the COVID-19
pandemic. Secondarily, we sought factors independently as-
sociated with clinician satisfaction with the quality of care
provided through telemedicine. The third goal was to deter-
mine if there were any factors independently associated with
telemedicine platform preference by clinicians.
NO. 00  MONTH 0000 TELEMEDICINE and e-HEALTH 1
 MINER ET AL.

Materials and Methods Table 1. Study Population

Institutional review board approval (2018-07-0137) was
n = 220
given and qualitative interviews were conducted in May
2020 with seven clinicians from a multispecialty group Years in practice, mean (SD) 13 (9.4)
a
known for their enthusiasm for telemedicine and early Population density, mean county rank (SD) 3.3 (1.6)
adoption in their practices, either before or after COVID-19- Patient population, n (%)
related changes. These qualitative interviews were analyzed Pediatric 55 (25)
using thematic content analysis and a survey was con-
Adult 125 (57)
structed to further elucidate these themes. Members of the
Both 40 (18)
physician group were invited to complete the survey through
e-mail and were provided with a description of the study Practice context, n (%)

and after which, completion of the questionnaire implied Outpatient 131 (60)
informed consent. Questionnaires were completed online Inpatient or both 89 (40)
using Qualtrix (Provo, Utah), a secure web-based survey Specialty, n (%)
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application.
Nonsurgical 166 (75)
Participants completed a survey about demograph-
Surgical 54 (25)
ics, telemedicine experience, satisfaction with various ele-
ments of telemedicine encounters, desired features in a Prior telemedicine experience, n (%)

telemedicine platform, personality elements, and prefer- No 193 (88)

ences. Demographic questions included years in practice, Yes 27 (12)
specialty, patient population, practice location, and practice Duration of telemedicine visits, minutes (SD)
context. Practice locations were approximated by county New patients 27 (13)
and counties were later stratified by population density, with
Follow-up 18 (9.3)
the most urban counties ranked higher than more rural
Platform features, mean rank (SD)
counties.
For questions pertaining to satisfaction with telemedicine Ease of use (patients) 1.3 (0.73)
care, clinicians were asked to rate their agreement with the Ease of use (clinician) 2.2 (1.0)
statements from totally disagree (-5) to totally agree (+5). Ability to have multiple people on the same call 4.3 (1.6)
Personality elements and preference-based questions were Ability to screen share 5.2 (1.6)
arranged on a sliding scale, with one element of comparison
Good customer service 5.1 (1.6)
listed on the far left (-5), the other on the far right (+5), and a
Ability to message patient 6.7 (1.3)
neutral response in the middle (0). Participants were asked to
state where on the continuum they identified themselves. For Integration with calendar 6.3 (1.7)
the question pertaining to desired telemedicine platform Integration with EMR 5.3 (2.1)
features, eight features noted from the qualitative interviews Other 8.6 (1.4)
were listed as well as an option for ‘‘other.’’ Participants were Platform experience, n (%)
asked to rank these features from most important to least
Google hangouts 195 (89)
important (1–9).
Zoom 62 (28)
A total of 241 participants responded. Twenty-one (8.7%)
were excluded from analysis as they completed <50% of the Web-based platform 56 (25)
survey. The final analysis included 220 subjects, with an av- Other 68 (31)
erage of 13 years of experience and 25% indicating a surgical Platform preference, n (%)
specialty (Table 1). Google hangouts 107 (49)
Zoom 31 (14)
STATISTICAL ANALYSIS
Web-based platform 31 (14)
Practice location information that was incomplete was
treated as missing data. These missing values were replaced Other 51 (23)
a
with the average of the other population density rank (mean Practice locations were approximated by county and then ranked from 1
imputation). Histograms and Shapiro–Wilk tests of normality representing the most urban counties to 7 representing the most rural.
EMR, electronic medical record; SD, standard deviation.

2 TELEMEDICINE and e-HEALTH M O N T H 0 0 0 0 ª MARY ANN LIEBERT, INC.

 CLINICIAN TELEMEDICINE PERCEPTIONS

showed non-normal distributions of the age, experience,

Table 2. Multivariable Logistic Regression of Factors
Associated with Continuing Telemedicine preference, and satisfaction measures. Categorical variables
After Coronavirus Disease-19 are presented as frequencies with percentages, and all con-
ODDS tinuous variables were represented as means with standard
RATIO 95% CI p deviations due to adequate sample size.
Telemedicine perceptionsa
In bivariate analysis, we compared differences among cli-
nicians who desire to continue using telemedicine after
Quality of care 2.7 1.5 5.2 0.002
COVID-19 and those who did not, using Pearson’s chi-squared
Quality of relationships 0.74 0.47 1.2 0.19 and Mann–Whitney tests. We also compared factors associ-
Diagnosis from history 0.84 0.52 1.3 0.46 ated with satisfaction with the quality of telemedicine care
Ease of physical examination 2.1 1.0 4.5 0.045 using Mann–Whitney tests, Kruskal–Wallis tests, and Spear-
man’s rank correlation coefficient. Finally, we compared the
Patient comfort 0.90 0.56 1.5 0.68
characteristics of those with a preference for specific tele-
b
Clinician preferences medicine platforms using Pearson’s chi-squared and Kruskal–
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Phone/video vs. in-person meeting 0.56 0.34 0.93 0.024 Wallis tests.
Clinician beliefs a Variables with a p-value of <0.01 on bivariate analysis
were entered into multivariable logistic and linear regression
Adaptability is important 2.0 1.0 3.8 0.044
models to assess the independent association of these ex-
Physical touch is important 0.56 0.28 1.1 0.10 planatory variables with the desire to continue telemedicine
Bold values indicate p < 0.05, all factors with a p < 0.01 were included in the after COVID-19, satisfaction with the quality of telemedicine
multivariable model.
a
care, and the preferred telemedicine platform (Tables 2–3).
Perceptions were scored on a scale from -5 representing totally disagree to
Results of the logistic regression are reported as odds ratios
5 representing totally agree.
b
Preferences were scored on a scale from -5 representing a total preference for
with standard error, 95% confidence interval (CI), and
the left scenario to 5 representing a total preference for the right scenario. p-value. Results of the linear regression are reported as
CI, confidence interval. coefficients, 95% CI, standard error, p-value, semipartial

Table 3. Multivariable Analysis of Factors Associated with Telemedicine Care Satisfaction

COEFFICIENT 95% CI STANDARD ERROR p SEMIPARITAL R2 ADJUSTED R2
Population density, county ranka -0.26 -0.43 -0.090 0.086 0.003 0.023 0.49
Duration of new patient visits, minutes 0.021 0.000 0.042 0.011 0.05 0.010
Preference for platform features, mean rankb
Ease of patient use -0.69 -1.03 -0.35 0.17 <0.001 0.041
c
Clinician preferences
Phone/video vs. in-person meeting -0.19 -0.30 -0.066 0.060 0.002 0.024
Working at the office vs. home 0.037 -0.063 0.14 0.051 0.47 0.0013
Clinician beliefsd
Adaptability is important 0.67 0.48 0.87 0.098 <0.001 0.118
Physical touch is important -0.15 -0.28 -0.021 0.066 0.023 0.013
Clinician personalityc
Judging vs. perceiving 0.13 0.022 0.23 0.053 0.017 0.015
Bold values indicate p < 0.05, all factors with a p < 0.01 were included in the multivariable model.
a
Practice locations were approximated by county and then ranked from 1 representing the most urban counties to 7 representing the most rural.
b
Platform features were ranked based on importance with 1 being most important and 9 being least important; cPreferences were scored on a scale from -5 representing
a total preference for the left scenario to 5 representing a total preference for the right scenario.
d
Perceptions were scored on a scale from -5 representing totally disagree to 5 representing totally agree.

ª M A R Y A N N L I E B E R T , I N C .  VOL. 00 NO. 00  MONTH 0000 TELEMEDICINE and e-HEALTH 3

 MINER ET AL.
R2, and R-squared values. Two-sided p-values <0.05 were
considered significant.
Results
Only 12% of the physicians had previously used tele-
medicine in their practice; during COVID-19, 96% are using
video visits to provide medical care. Among physicians now
using telemedicine, 91% plan to continue to offer tele-
medicine services after the resolution of physical distancing
and other adjustments to the pandemic.
Most clinicians ranked patient ease of use as the most im-
portant feature a platform can offer (mean rank 1.3 – 0.73) and
clinician ease of use followed closely behind (mean rank
2.2 – 1.0) (Table 1).
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Accounting for potential confounding using multivariable
analysis, desire to continue offering telemedicine visits after
the COVID-19 pandemic was associated with a higher satis-
faction with the quality of telemedicine care, endorsement of
the ease of performing a physical examination with tele-
medicine, belief that adaptability is an important element of
being a clinician, and less preference for in-person work
meetings over virtual meetings (Table 2).
Accounting for potential confounding using multivariable
analysis, higher satisfaction with the quality of telemedicine
care was associated with belief that adaptability is an im-
portant element of being a clinician, clinicians who identify as
being more perceiving (value flexibility) than judging (value
organization), providers from more urban counties, those who
rank patient ease of use as a more important element of a
telemedicine platform, and those with less preference for in-
person work meetings over virtual meetings (Table 3).
Discussion
The early experience with telemedicine was promising,1–5,16
but uptake was slow until the COVID-19 pandemic. We studied
factors associated with clinician desire to continue telemedicine
services after the COVID-19 pandemic and factors associated
with clinician satisfaction with the quality of care provided
through telemedicine.
The findings of this study can be interpreted in light of some
limitations. There are about 1,500 physicians in the multi-
specialty group, and some people started but did not complete
the survey. We anticipated a low response rate as it is typical
for survey studies. Although the group that responded may or
may not be representative of the larger group or the average
physician, we think the statistical associations with other
factors and answers to other questions are likely reproducible
in other settings and populations. The survey was adminis-
tered within <2 months of drastic changes in medical practice
4 TELEMEDICINE and e-HEALTH M O N T H 0 0 0 0
due to the pandemic and opinions and preferences may con-
tinue to evolve.
Consistent with prior studies, the key factor desired in a
platform was patient ease of use. Studies of hospital physi-
cians in South Korea, India, Hong Kong, United States, and
Spain found that overall satisfaction17 and perceived ease of
use18–21 directly impacts both the perceived usefulness and
the intention to use telemedicine.
The observation that desire to continue offering tele-
medicine visits after the COVID-19 pandemic correlates not
only with confidence with the examination and satisfaction
with the modality,22 but also with personal factors such as
belief that adaptability is an important element of being a
clinician, clinicians who identify as being more perceiving
(value flexibility) than judging (value organization), and less
preference for in-person work meetings over virtual meetings
suggests that clinicians who are going to have less preference
for telemedicine going forward can be identified by other
traits and preferences. In the qualitative interviews along with
our personal observations and interactions, including prior
investigations,23,24 we found that both clinicians and patient
concerns about telemedicine are things that lessen after a good
telemedicine experience. The pandemic has provided many
more clinicians and patients with good telemedicine experi-
ences and the likelihood of continued use is high. Telemedicine
will likely be a key part of the practice of clinicians who like to
evolve and adapt and already value the conveniences that
technology provides. However, there may be other personality
factors and preferences associated with more enthusiastic
adoption of telemedicine that we did not think to test.
The findings that higher satisfaction with the quality of tele-
medicine care was also associated with personal factors such as
the belief that adaptability is an important element of being a
clinician and clinicians who identify as being more perceiving
(value flexibility) than judging (value organization) suggests
that clinicians’ personality and beliefs can affect telemedicine
utilization. The observation that higher satisfaction with the
quality of telemedicine care was associated with urban location
is compatible with a study in Norway that showed small hos-
pitals are less likely to use telemedicine because it decreases the
need for physical presence of clinicians, and might lead to
difficulties with recruitment and retention of clinicians to rural
sites.25 The American Medical Association Physician Bench-
mark Survey found that the financial burden of implementing
telemedicine may be a barrier for small practices.26
Conclusions
Based on the results of this survey study and consistent with
personal observations in our daily work, telemedicine is going
ª MARY ANN LIEBERT, INC.

to be advanced first by physicians who tend to be flexible,
value technology-based practices, and who view adaptability
as an important element of being a clinician. Additionally, we
observed that clinicians who feel they can readily adapt the
physical examination to video, and those that believe they can
accomplish the goals of a meeting without being in the same
room are more likely to be telemedicine proponents. People in
your organization with these beliefs can more readily help
bring telemedicine forward and help create institutional
change. Future studies can develop the noted association of
clinician personality aspects and their preferences and satis-
faction with telemedicine utilization.
Disclosure Statement
Downloaded by 84.54.58.107 from www.liebertpub.com at 09/19/20. For personal use only.
None of the authors have any financial and personal rela-
tionships with other people or organizations that could in-
appropriately influence (bias) this study.
Funding Information
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
REFERENCES
1. Buvik A, Bergmo TS, Bugge E, Smaabrekke A, Wilsgaard T, Olsen JA. Cost-
effectiveness of telemedicine in remote orthopedic consultations: Randomized
controlled trial. J Med Internet Res 2019;21:e11330.
2. Ohinmaa A, Vuolio S, Haukipuro K, Winblad I. A cost-minimization analysis of
orthopaedic consultations using videoconferencing in comparison with
conventional consulting. J Telemed Telecare 2002;8:283–289.
3. Harno K, Arajärvi E, Paavola T, Carlson C, Viikinkoski P. Clinical effectiveness
and cost analysis of patient referral by videoconferencing in orthopaedics.
J Telemed Telecare 2001;7:219–225.
4. Buvik A, Bugge E, Knutsen G, Småbrekke A, Wilsgaard T. Quality of care for
remote orthopaedic consultations using telemedicine: A randomised controlled
trial. BMC Health Serv Res 2016;16:483.
5. Buvik A, Bugge E, Knutsen G, Småbrekke A, Wilsgaard T. Patient reported
outcomes with remote orthopaedic consultations by telemedicine: A
randomised controlled trial. J Telemed Telecare 2019;25:451–459.
6. Dick PT, Filler R, Pavan A. Participant satisfaction and comfort with
multidisciplinary pediatric telemedicine consultations. J Pediatr Surg 1999;34:
137–142.
7. Mulgrew KW, Shaikh U, Nettiksimmons J. Comparison of parent satisfaction
with care for childhood obesity delivered face-to-face and by telemedicine.
Telemed J E Health 2011;17:383–387.
8. von Wangenheim A, de Souza Nobre LF, Tognoli H, Nassar SM, Ho K. User
satisfaction with asynchronous telemedicine: A study of users of Santa Catarina’s
system of telemedicine and telehealth. Telemed J E Health 2012;18:339–346.
9. Agha Z, Schapira RM, Laud PW, McNutt G, Roter DL. Patient satisfaction with
physician–patient communication during telemedicine. Telemed J E Health
2009;15:830–839.
10. Armer JM, Harris K, Dusold JM. Application of the concerns-based adoption
model to the installation of telemedicine in a rural Missouri nursing home.
J Nurses Prof Dev 2004;20:42–49.
ª M A R Y A N N L I E B E R T , I N C .  VOL. 00
CLINICIAN TELEMEDICINE PERCEPTIONS
11. Dickens BM, Cook RJ. Legal and ethical issues in telemedicine and robotics. Int
J Gynecol Obstet 2006;94:73–78.
12. Fatehi A, Gonzalez A, Ring DC, Queralt M. Psychosocial factors are associated
with electronic portal registration. Clin Orthop Relat Res 2020: [Epub ahead of
print]; DOI: 10.1097/CORR.0000000000001278.
13. Kahn EN, La Marca F, Mazzola CA. Neurosurgery and telemedicine in the United
States: Assessment of the risks and opportunities. World Neurosurg 2016;89:
133–138.
14. Norton SA, Lindborg CE, Delaplain CB. Consent and privacy in telemedicine.
Hawaii Med J 1993;52:340–341.
15. Silverman RD. Current legal and ethical concerns in telemedicine and
e-medicine. J Telemed Telecare 2003;9(1_suppl):67–69.
16. Tyrrell Burrus M, Werner BC, Starman JS, et al. Patient perceptions and current
trends in internet use by orthopedic outpatients. HSS J 2017;13:271–275.
17. Segrelles-Calvo G, Chiner E, Fernández-Fabrellas E. Acceptance of
telemedicine among healthcare professionals. Arch Bronconeumol Engl Ed
2015;51:611–612.
18. Dash M. Physician’s attitude towards acceptance of telemedicine
technology for delivering health care services. Int J Mech Eng Technol
2018;09:715–722.
19. Hu PJ, Chau PYK, Sheng ORL, Tam KY. Examining the technology acceptance
model using physician acceptance of telemedicine technology. J Manag Inf
Syst 1999;16:91–112.
20. Kahn JM, Rak KJ, Kuza CC, et al. Determinants of intensive care unit
telemedicine effectiveness. An ethnographic study. Am J Respir Crit Care Med
2019;199:970–979.
21. Rho MJ, Choi I young, Lee J. Predictive factors of telemedicine service
acceptance and behavioral intention of physicians. Int J Med Inf 2014;83:559–
571.
22. Kissi J, Dai B, Dogbe CS, Banahene J, Ernest O. Predictive factors of physicians’
satisfaction with telemedicine services acceptance. Health Informatics J 2020;
26:1866–1880.
23. Cottrell MA, Hill AJ, O’Leary SP, Raymer ME, Russell TG. Clinicians’ perspectives
of a novel home-based multidisciplinary telehealth service for patients with
chronic spinal pain. Int J Telerehabilitation 2018;10:81–88.
24. Powell RE, Henstenburg JM, Cooper G, Hollander JE, Rising KL. Patient
perceptions of telehealth primary care video visits. Ann Fam Med 2017;15:
225–229.
25. Alami H, Gagnon MP, Wootton R, Fortin JP, Zanaboni P. Exploring factors
associated with the uneven utilization of telemedicine in Norway: A mixed
methods study. BMC Med Inform Decis Mak 2017;17:180.
26. Kane CK, Gillis K. The use of telemedicine by physicians: Still the exception
rather than the rule. Health Aff (Millwood) 2018;37:1923–1930.
Address correspondence to:
David Ring, MD, PhD
Department of Surgery and Perioperative Care
Dell Medical School
University of Texas at Austin
Austin, TX 78712
USA
E-mail: david.ring@austin.utexas.edu
Received: July 19, 2020
Accepted: August 28, 2020
Online Publication Date: September 21, 2020
NO. 00  MONTH 0000 TELEMEDICINE and e-HEALTH 5