Patients’ Perception of Telemedicine in a Large Urban Inner-City Emergency Department: A Cross-Sectional Survey

Introduction Telemedicine has the potential to ease emergency department (ED) overcrowding, improve ED throughput, and decrease the cost of medical care. Much of the current knowledge of telemedicine systems focuses on bringing more specialty care to the ED or improving access in rural areas. Limited research exists on patients’ perception of telemedicine in an urban ED. Methods A survey exploring perceptions of telemedicine encounters was distributed to both providers and patients following mirrored encounters between October 2015 and August 2016. Chi-square analysis was conducted to identify associations between factors and openness to telemedicine from the patients’ perspective. Results A total of 174 patients were included in the analysis. Factors associated with patient willingness to try telemedicine included: having access to a tablet with internet (p=0.0023), having access to a tablet with camera (p=0.0025), having downloaded apps in the past (p=0.0028), having used an app in the past (p<0.0001), and had frequent video chat in the past (p=0.0142). Conclusion With widespread access to smartphones with internet connectivity and pressing demands for healthcare services, telemedicine may provide a potential solution to low acuity medical care needs.


Introduction
In the United States, between 2006 and 2011, the total amount of annual visits to emergency departments (EDs) increased by 4.5% from 40,200 to 42,100 per 100,000 population, which may include repeated visits by the same individual [1]. In a 2011 analysis of ED visits resulting in discharge, the most common conditions included fever in infants, otitis media, viral illnesses, superficial injuries, abdominal pain, back pain, headache, and urinary tract infections [2]. Many of these low acuity conditions could potentially be diagnosed and treated using telemedicine [2][3][4].
Telemedicine, the provision of health care via telecommunication and information technology, is a significant and rapidly growing component of healthcare in the United States [5]. The swift evolution of information technology and widespread use of the internet since the 1980s has pushed telemedicine from a 40-year-old concept into present-day application [6,7]. This change has been facilitated by high-speed telecommunication which allows for real-time transfer of information, images, and videos [6]. Many medical specialties, including EDs, have considered how the application of telemedicine may become an important alternative to in-person healthcare treatment [6]. Additionally, telemedicine may be able to eliminate the distance and cost barriers that hinder medical aid today, therefore leading to improved access to medical services [6,8]. Furthermore, telemedicine has been suggested as a useful tool to offset physician shortages [9,10].
Telemedicine may have the potential to safely ease ED overcrowding, reduce ED ambulance transports, improve ED throughput by integrating specialty services, and decrease the cost of medical care [8,[11][12][13][14][15][16]. Rademacher and colleagues reported that using telemedicine for screening patients in the ED significantly

Materials And Methods
A cross-sectional, prospective study was conducted via questionnaires targeting both providers' and patients' perceptions of telemedicine between October 2015 to August 2016 at Arrowhead Regional Medical Center (ARMC) in San Bernardino County, California. Questionnaires were distributed to both providers and patients for mirrored encounters via SurveyMonkey. The ARMC ED is one of the busiest EDs in the state of California with more than 100,000 annual visits [24]. San Bernardino County is the largest county in the United States with an estimated population of 2 million with approximately 49% of Hispanic or Latino ethnicity [25].
Data were collected through a questionnaire on SurveyMonkey (Appendix A). The survey consisted of 20 questions, eight of which were answered by the ED provider (attending physician, resident physician, or physician assistant) and the remainder of which were answered by participating patients. The questionnaires addressed patient demographics, access to technology, and computer literacy (Appendix A). The survey also addressed both provider and patient perceptions regarding telemedicine versus in-person healthcare for the visit. Research assistants interacted with ED providers and patients with low acuity illness, and in real-time entered participants' responses into SurveyMonkey for data collection. Patients were blinded to providers' answers and vice versa. Additionally, if a patient had difficulty with literacy, the research assistants read the questions to the patients. The questionnaires were available in English and Spanish and a certified translator was provided when necessary. The questionnaires were completed at various times throughout the day, covering all operational hours of the ED. This study was reviewed and approved by the Institutional Review Board at ARMC.
All statistical analyses were conducted using the SAS software for Windows, version 9.3 (SAS Institute Inc., Cary, NC). Descriptive statistics were presented as frequencies and proportions for categorical variables. Chi-square analysis was conducted to assess the association between various variables (including demographic variables and access to technology) and willingness to try telemedicine. All statistical analyses were two-sided. P-value <0.05 was considered statistically significant.

Results
Among the initial 188 participants who were surveyed, 14 participants were excluded (seven for incomplete surveys and an additional seven due to admission to hospital). A final 174 (92.6%) patients were included in the analysis.  Regarding patient's access to technology, three areas were assessed: accessibility to a cell phone, tablet, and computer (  Additionally, the current study showed the majority of surveyed patients have access to cell phone technology, and close to half have access to tablet and computer technology. Despite a regional poverty level of 17.6%, more than 80% of the patients in this study had cell phones with internet capability and a functional camera. Nationally, both cell phone and smartphone usage has steadily increased with 95% of American adults owning a mobile device and 77% of American adults owning a smartphone as of November 2016 [27]. For the Latino population, who present as the majority of the participants in this study and the surrounding region, the ownership and use of mobile technology generally reflect a similar upwards trend [26]. While there may be a variation in each individual's proficiency in using technology, the wide ownership of mobile technology may have led to participants' readiness to utilize telemedicine [28].
In order to correlate previous use of mobile technology with proficiency in using technology and willingness to utilize telemedicine, this study examined the past usage of mobile technology of the participants. Approximately 80% of the participants stated they had downloaded and used an app in the past, and approximately 60% had experience using video chat software. While the study did not stratify app use with the age of participants, it suggests that previous app and video chat use may be correlated with increased acceptance of telemedicine.
Reasons for the relatively high willingness to utilize telemedicine may be related to increased access for those in the low socioeconomic population. Previous studies have shown that access to telemedicine services generally results in increased equity among different socioeconomic groups in the pediatric population [17]. Causes for this change in low socioeconomic groups may include reduced missed work, easier and more convenient access to health care, and availability of health care access outside of traditional business hours [17,19].
While our study suggests the potential for telemedicine to improve healthcare access and alleviate utilization of the ED for low-acuity care, there may be potential limitations. Patient barriers may include financial concerns and health and technology literacy issues, both of which may hinder the sustainability of telemedicine. While reimbursable telemedicine visits may be favored, commercial telemedicine may incur additional health costs that could not be supported by a low-income population. Additionally, patients may lack familiarity with technology or have low health literacy, which may further complicate the use of telemedicine for conducting a remote visit. Proper reimbursement via state Medicaid programs and patient education may allow patients to overcome such barriers. Furthermore, judging from the majority of patients' willingness to try telemedicine in this study, many tangible and intangible benefits such as scheduling convenience, less interference with work schedule and childcare, and eliminating transportation barriers may make this option more attractive to many of these patients [19].

Limitations
The generalizability of findings in the current study was limited by the sample size of 174 patients in the study within an 11-month period. The proportion of Hispanic (59.2%) in the current study was similar to the national statistics of the Hispanic population in San Bernardino County (61.9%) [25]. While our findings may be generalizable to urban ED demographics, they may have limited generalizability for higher socioeconomic demographics and those with private insurance. Future research is needed to explore the effects of income and insurance coverage in relation to user preferences of telemedicine.

Conclusions
With the onset of ubiquitous smartphone access, rapid and widely accessible internet connectivity, and pressing demands for healthcare services, telemedicine may provide a potential solution to the low acuity medical care needs of many communities, particularly those low socioeconomic communities.

Appendices
Appendix A -Questionnaire

Additional Information Disclosures
Human subjects: Consent was obtained by all participants in this study. Arrowhead Regional Medical Center IRB issued approval 15-31. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.