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Telemedicine, or electronic interactive health care consultation, offers a variety of benefits to both patients and primary care clinicians. However, little is known about the opinions of physicians using these modalities.
The aim of this study was to examine physician perceptions, including challenges, risks, and benefits of the use of telemedicine in human immunodeficiency virus (HIV) patient care.
A Web-based, self-administered, anonymous, cross-sectional survey was sent to physicians known to be providing medical care to patients living with HIV in Ontario, Canada. Descriptive statistics and frequencies were used to examine physician perceptions and characteristics of participants.
Among the 51 invited participants, 48 (94%) completed the survey. Sixty-two percent (29/47) of respondents reported that they used some form of telemedicine to care for HIV patients in their practice. Of the respondents who identified as having used telemedicine in their practice, telephone (86%, 25/29), email (69%, 20/29), and teleconsultation (24%, 7/29) were listed as frequent modalities used. A significant number of physicians (83%, 38/46) agreed that an obstacle to adopting telemedicine is their perception that this modality does not allow for a comprehensive assessment of their patients’ health. In addition, 65% (28/43) of physicians agreed that patients may not feel adequately connected to them as a provider if they used telemedicine. However, 85% (39/46) of respondents believed that telemedicine could improve access and timeliness to care along with increasing the number of times physicians can interact with their patients.
From the perceptions of physicians, telemedicine shows promise in the care of patients living with HIV. More than half of the respondents are already using telemedicine modalities. Whereas many physicians are concerned about their ability to fully assess the health of a patient via telemedicine, most physicians do see a need for it—to reduce patient travel times, reduce exposure to stigma, and improve efficiency and timely access to care. Challenges and risks such as technological gaps, confidentiality, and medicolegal concerns must be addressed for physicians to feel more comfortable using telemedicine.
Telemedicine, or electronic interactive health care consultation, offers a variety of benefits to both patients and primary care clinicians [
Human immunodeficiency virus (HIV) is a highly complex chronic illness and should be thought of as a myriad of conditions and not one single issue. Many patients suffering from HIV are also afflicted with physical and psychological impairments, making the use of telemedicine in this population a strong compliment to current treatment options [
Physicians who were providing medical care to people living with HIV in Ontario, Canada were asked to complete a Web-based, self-administered, and anonymous survey regarding the use of telemedicine in HIV care.
A list of all registered infectious disease specialists in the province (n=218) was obtained via the College of Physicians and Surgeons of Ontario. Of these, 51 individuals were identified as providing HIV-specific care. A link to the survey was emailed to these individuals. In addition, 2 additional email reminders were circulated 1 week apart to get as many responses as possible.
Only physicians practicing in Ontario and who have HIV patients in their care were included in this study. All participants provided informed consent.
A total of 48 participants completed a cross-sectional survey hosted by FluidSurveys [
The aims of the survey were to better understand current practices and perceived risks, benefits, and challenges in using telemedicine in HIV care. To do this, questions were organized into 5 sections: (1) general concepts of telemedicine, (2) perceived challenges to telemedicine use, (3) benefits of telemedicine, (4) perceived risks of telemedicine, and (5) information about the health care provider and their practice and patient population.
Data were analyzed using descriptive statistics and frequencies to examine the characteristics of invited participants and their responses to the survey items. Data are presented as total counts and percentages. For simplicity, physician perceptions were dichotomized by aggregating the categories “agree” and “strongly agree” to “agree” in the text, while “disagree” and “strongly disagree” were combined to “disagree.” In addition, “minor,” “moderate,” and “severe” barriers were consolidated to “barrier” in the text. Data synthesis and statistical analyses were performed using R 3.2.3 (R Core Team, Vienna Austria) [
This study was approved by the Research Ethics Board at St Michael’s Hospital in Toronto, Canada (REB#15-337). Per our study protocol, participation was completely voluntary. All questions were self-administered and anonymous. Participants were not compensated for completing the survey and were free to withdraw or not answer any questions they did not want to with no professional or other consequences.
Of the 51 physicians who were invited to take part in the Web-based survey, 50 (98%) consented to participate in the study. Two physicians who consented were removed because they did not answer any of the survey questions. All questions had 10% or fewer missing items, with most having only 4% missing.
Physician characteristics are presented in
More than half of the physicians (62%, 29/47) reported that they used some form of telemedicine to care for HIV patients in their practice. Eighteen (38%, 18/47) respondents stated that they have never used telemedicine in their practice. Of the 29 respondents who were identified as having used telemedicine in their practice, telephone (86%, 25/29), email (69%, 20/29), and teleconsultation (24%, 7/29) were listed as frequent modalities used to care for patients. HIV care providers were more likely to use the telephone (69%, 20/29) to care for their patients as opposed to email (21%, 6/29) and teleconsultation systems (10%, 3/29;
When requiring the assistance of a specialist in order to care for HIV patients, about half of the physicians (55%, 26/47) reported that they used telemedicine in order to consult with specialists. However, 21 respondents (46%, 21/47) stated that they have never used telemedicine to contact a specialist. The primary modalities used to consult with a specialist by the 26 respondents were email (58%, 15/26) and telephone (38%, 10/26).
Characteristics of participants (N=48).
Participant characteristics | Number of respondents |
|
Toronto or Ottawa | 37 (77) | |
Other locations in Ontario | 11 (23) | |
Family medicine | 20 (44) | |
Infectious disease | 16 (36) | |
Other (ie, internal medicine, psychiatrist, etc) | 9 (20) | |
<10 | 10 (22) | |
10-15 | 8 (18) | |
16-24 | 12 (27) | |
≥25 | 15 (33) | |
< 25% | 14 (31) | |
25-49% | 12 (27) | |
50-74% | 9 (20) | |
75-100% | 10 (22) | |
Phone consultations | 25 (86) | |
Email consultations | 20 (69) | |
Teleconsultation systems | 7 (24) | |
Other (ie, instant messaging software) | 1 (3) | |
Never or rarely | 29 (60) | |
Sometimes | 11 (23) | |
Often | 7 (15) |
aHIV: human immunodeficiency virus.
Twenty-six physicians (55%, 26/47) felt that there was a need to expand the use of HIV telemedicine services in Ontario; however, 20 physicians (43%, 20/47) were unsure of the need for an expansion of HIV telemedicine services, with 1 physician expressing a negative response to the development of telemedicine services in Ontario. Whereas only 26 physicians expressed interest in developing telemedicine services for HIV patients, many physicians (28/46, 61%) stated they served patients who could benefit from telemedicine. There were also a significant number of physicians who stated that they provided care to a number of patients who had difficulties traveling because of physical disabilities or mental health issues (82%, 37/45 and 72%, 34/47 respectively). Also, 74% (34/46) of those surveyed stated they had patients who traveled more than 100 kilometers for a visit.
Physicians endorsed various challenges relating to the use of telemedicine when caring for HIV patients (
Respondents expressed opinions regarding the perceived risks of using telemedicine for patients living with HIV (
The majority of physicians stated that HIV patients would benefit from the use of telemedicine (
Participants’ perspectives on challenges to using telemedicine.
Perceived challenges to using telemedicine | No barrier |
Minor barrier |
Moderate barrier |
Severe barrier |
It takes too much time | 17 (38) | 20 (44) | 6 (13) | 2 (4) |
I lack access to the necessary technology | 18 (40) | 9 (20) | 15 (33) | 3 (7) |
I have no patients that require telemedicine services | 33 (75) | 7 (16) | 1 (2) | 3 (7) |
Most of my patients do not have access to the necessary equipment for telemedicine | 11 (24) | 12 (27) | 19 (42) | 3 (7) |
I have concerns about confidentiality | 18 (40) | 17 (38) | 7 (16) | 3 (7) |
There is too much diversity in my practice to adopt telemedicine as a regular practice | 26 (58) | 13 (29) | 5 (11) | 1 (2) |
I cannot adequately assess a patient using telemedicine | 8 (17) | 19 (41) | 15 (33) | 4 (9) |
I have concerns about remuneration for telemedicine | 17 (38) | 12 (27) | 10 (22) | 6 (13) |
I worry that patients will abuse the use of telemedicine to communicate with me | 13 (29) | 16 (36) | 15 (33) | 1 (2) |
I have medicolegal and licensing concerns about using telemedicine | 22 (49) | 15 (33) | 8 (18) | 0 |
Participants’ perspectives on risks of telemedicine.
Perceived risks of using telemedicine | Strongly disagree |
Disagree |
Agree |
Strongly agree |
I am concerned that telemedicine will increase the social isolation experienced by people living with HIVa | 4 (9) | 29 (67) | 7 (16) | 3 (7) |
Patients may not feel adequately connected to me as a health care provider | 3 (7) | 12 (28) | 22 (51) | 6 (14) |
Patients will receive lesser quality assessments | 3 (7) | 15 (35) | 20 (47) | 5 (12) |
Patients may not understand my instructions | 3 (7) | 20 (47) | 19 (44) | 1 (2) |
Remote patients will lose the opportunity to come see me in person if they prefer it | 3 (7) | 26 (60) | 13 (30) | 1 (2) |
aHIV: human immunodeficiency virus.
Participants’ perspectives on benefits of telemedicine.
Perceived benefits of using telemedicine | Strongly disagree |
Disagree |
Agree |
Strongly agree |
Reduces their exposure to stigma (in rural areas, for example, acquaintances or family would not see them visit medical services) | 0 | 8 (17) | 34 (74) | 4 (9) |
Increases their privacy | 0 | 16 (35) | 26 (57) | 4 (9) |
Reduces travel time | 0 | 0 | 15 (33) | 31 (67) |
Improves quality of patient care | 1 (2) | 17 (37) | 21 (46) | 7 (15) |
Improves efficacy of patient care | 0 | 15 (33) | 22 (48) | 9 (20) |
Increases the number of times we can interact | 0 | 7 (15) | 29 (63) | 10 (22) |
Improves access and timeliness to care | 0 | 7 (15) | 28 (61) | 11 (24) |
The aim of this study was to help describe physicians’ perceptions of the use of telemedicine to care for patients living with HIV and the perception they have of their patients’ use of telemedicine; the barriers and facilitators. In terms of benefits, physicians agreed across the board that telemedicine services would decrease travel times and could likely reduce patient experience of HIV-related stigma at appointments. Physicians also felt that telemedicine would increase access and efficiency of care, while benefiting patients who have difficulty travelling due to physical and mental impairments.
We discovered some consistent trends when evaluating the perceived challenges physicians reported to using telemedicine in their practice. Physicians most notably reported apparent issues around lack of time for telemedicine, lack of necessary technology for the patient and the provider, as well as concerns about confidentiality, remuneration, and inability to adequately assess patients using the service. These results echo some of the current sentiments regarding the uptake of telemedicine into general medical practice [
Although there was consistent agreement around possible benefits of telemedicine for HIV care, our findings highlight many perceived challenges and risks that must be addressed before HIV telemedicine is likely to expand dramatically in practice. Confidentiality, privacy, and remuneration were reported as key challenges to physicians adopting telemedicine in Ontario. These challenges may primarily be due to a lack of information on the physicians’ part in regards to the telemedicine services at their disposal and have less to do with regulation limitations, or limitations of the technology. Previous research has shown that physicians are less likely to use telemedicine services on a regular basis if they are not adequately compensated for their time and effort [
Some of these data reflect current themes in distance education; the impact of in-person consultation is glamorized, whereas “Web-based presence” is misunderstood as impersonal. In many responses, it seems that physicians fear that the introduction of telemedicine into practice will be a replacement to in-person consultations and not a compliment to current practices. The nature of HIV as a complex syndrome of various clinical manifestations may also be contributing to the physicians’ hesitation to endorse telemedicine. For example, people living with HIV may have complex social, financial, and psychological concerns that seem less amenable to telemedicine techniques when a provider is inexperienced with these remote modalities.
In Canada, the Canada Health Infoway, which is a national initiative, was created to expedite the development and adoption of telemedicine services while addressing reported barriers to the implementation of eHealth systems. Through the use of provincial partners like the Ontario Telemedicine Network, the infrastructure is in place to provide telemedicine services to those receiving care for HIV. The use of telemedicine to treat other chief health complaints has shown positive results as evidenced by the success of Telehomecare, Telestroke, and Teledermatology programs in Ontario [
Telemedicine networks in Canada offer education for physicians and their staff around remuneration, the technology of telemedicine, as well as ways to incorporate telemedicine alongside in-person care. Physicians and health care providers may need ongoing training and support in the form of distance educational sessions to gain up-to-date and meaningful instruction on the benefit of telemedicine services and how to seamlessly integrate them into their practices. By providing physicians with evidence-based research on the growing need for innovative care and the benefits of implementing telemedicine services, their perspectives may change and allow for a greater adoption of the service in HIV care provision.
In terms of collecting respondent characteristics, we collected few demographic identifiers in order to protect confidentiality of northern providers that may be using telemedicine more often or more proficiently than tertiary providers. We also did not gather the ages or genders of physicians who responded in our survey, which could possibly be a predictor of telemedicine perceptions. We also were not able to gather opinions of all physicians practicing HIV care in Ontario, as there is not a full, up-to-date registry of these physicians.
From the perceptions of physicians, telemedicine shows promise in the care of patients living with HIV. More than half of the respondents are already using telemedicine. Whereas many physicians are concerned about their ability to fully assess the health of a patient via telemedicine, most physicians do see a need for it to reduce patient travel times, reduce exposure to stigma, and improve efficiency and timely access to care. Challenges and risks such as technological gaps, confidentiality, and medicolegal concerns must be addressed for physicians to feel more comfortable using telemedicine. Further research is warranted to determine the levels and needs for training of physicians and patients on various telemedicine modalities and technologies. Also, there is a need to compare and contrast the data collected with research evidence in telemedicine uptake in other health areas such as wound care, diabetes, and counseling.
human immunodeficiency virus
This study was funded by a small grant from St Michael’s Hospital family health team, and was supported in kind by staff time at the Ontario HIV Treatment Network. Neither organization had any influence in the content of the survey or resulting publication, nor review or approval of the paper prior to publication.
The authors would like to acknowledge the HIV primary care physician team at St Michael’s Hospital, as well as Drs Sean Rourke and Rob Williams for their thorough review and edits of the survey.
Authors KA, TF, FIC, and JG were extensively involved in the creation and distribution of the survey, analysis of results, and drafting of the manuscript. All authors read and approved the final manuscript.
None declared.