Background: Coronavirus disease 2019 (COVID-19) pandemic has profoundly increased utilization of tele-medicine worldwide, particularly virtual visit, also known as tele consultation to replace majority of traditional in-person visit to continue deliver care whilst reduce risk of transmission to both healthcare provider and patients. In Malaysia, tele consultation allowed continuous outpatient care and timely follow-up visit when movement control was employed against COVID 19 outbreak. As tele consultation was not popular in Malaysia before pandemic, this study aimed to determine demographic characteristic and feedback of patients attended teleconsultation through video conferencing using a tele-medicine satisfaction survey.

      Subjects and methods: Online tele-medicine survey was sent to patients attended teleconsultation between March, 2020 to November, 2020 via WhatsApp. Tele-health usability questionnaire (TUQ) was used to assess patient satisfaction in term of 1) usefulness, 2) ease of use and learn ability, 3) interface quality, 4) interaction quality, 5) reliability, and 6) satisfaction and future use of teleconsultation. Patients gave their feedback based on 7-point Likert scale.

      Results: In total, 150 responses were gathered. Average score of each aspects and total average score were higher than 5. Usefulness had the highest score whereas reliability had the lowest. According to the responses, teleconsultation system used in present study was easy to learn and use, patients agreed teleconsultation is an acceptable way of healthcare delivery, they were able to have satisfactory interaction and communication with healthcare provider and they liked using it.

      Conclusion: Overall, patients showed positive response to virtual clinic visit and its utility as alternative healthcare delivery.

      Tele-medicine is the use of Information and Communication Technologies (ICT) to facilitate exchange of medical information and increase access to healthcare by overcoming geographical barrier [1]. It has broad applications involving transfer of medical information, consultation, diagnosis and treatment, health monitoring as well as follow up visit, over a distance [2]. One of the main components of tele-medicine is teleconsultation, also known as virtual clinic visit, which enables remote communication between patient and healthcare providers or specialist, omits the need of long distance travelling and minimize associated risk of deterioration of health condition. Additionally, patients can have access to healthcare providers that would otherwise be inaccessible due to geographical barrier. Tele-medicine is also beneficial for exchange of new information, treatment and experience between health professionals from different sites [3]. Teleconsultation can be in asynchronous store-and-forward mode via email or synchronous mode via interactive real time video conferencing [4].

      In Malaysia, tele-medicine was initiated by Ministry of Health (MOH) in 1997 to harness the power of ICT in developing equitable, accessible and affordable healthcare system to offer high quality of care for better health outcomes and wellness of nation [5]. As an early effort, a teleconsultation pilot study (March 2001-September 2002) was undertaken to install telecommunication equipments in 41 hospitals and health centers across Malaysia and established nationwide teleconsultation network [6,7]. This project helped in recognizing the potential of teleconsultation as an effective means of healthcare delivery by improving the access to healthcare service, especially in rural areas where medical resources are scarce. Through teleconsultation referral, patients were successfully referred to specialist of appropriate level of care for remote consultation, thereby eliminate geographical constraint and in most of the cases, the need to travel. It has been reported teleconsultation reduced the number of physical referral and unnecessary inter-hospital transfer of patients [7]. The number of hospitals interlinked within the network increased from 41 in 2000 to 52 in 2010 [5]. Other tele-medicine projects were attempted, yet, unestablished infrastructure and technology along with low acceptance at that time led to little achievement [8].

      Emergence of COVID-19 has escalated use of tele-medicine around the world as it reduces risk of transmission to both patients and healthcare providers [9,10,11,12,13] . In Malaysia, the first case of COVID-19 was reported on 25th January, 2020. Subsequent outbreak in March 2020 forced Malaysian government to impose Movement Control Order (MCO) nationwide as an effort to contain the spread of coronavirus by restricting movements of nation and travels across states [14,15]. However, such movement control limited the accessibility to healthcare, especially those live in area with limited medical resources, and interrupted outpatient appointment and follow-up visit. In response to these challenges, private healthcare has invested in virtual clinic visit to ensure patients receive continuous care in the settings of pandemic and movement control.

      Although COVID-19 pandemic has encouraged use of tele-medicine in Malaysia, challenges such as lack of experience and clear tele-medicine guidelines in private hospitals may have caused significant doubts for healthcare professionals and resulted in issues during virtual clinic visit. In addition, since teleconsultation in private clinic is at its early implementation, clinical characteristic of patients, patient acceptance and feedback for virtual clinic are lacking. In view of this, present study aimed to determine the clinical characteristics and feedbacks of patients attending virtual clinic in Sunway Medical Centre Velocity (SMCV) and another Sunway Medical Centre located in Bandar Sunway (SUNMED) by the means of cross-sectional survey. We hope findings of present study could be useful for refining teleconsultation to encourage its adoption and acceptance in the following stage of pandemic and post pandemic.

Sample population

      In order to collect demographic characteristics and feedbacks of patients who attended virtual clinic in SUNMED and SMCV between March 2020 and November 2020, an institution-based cross-sectional survey was conducted. Patients who had virtual visit and with no life-threatening condition, cognitive issues and hearing impairment were invited to answer the tele-medicine satisfaction survey in Google Forms through WhatsApp message. Participation was voluntary and survey was anonymized. All data collected was treated as confidential.

Study instrument

      For the purpose of this study, tele-medicineis referred to virtual visit through video conference. Tele-medicine satisfaction survey consist of three parts, which are 1) consent form, 2) personal particular of respondents and 3) a questionnaire intended to gain insights into their feedbacks on tele-medicine visit. After patients consented their participation, they answered personal particulars pertaining to their sociodemographic characteristics, which involve age, gender, ethnicity, nationality, living arrangement, marital status, occupation, monthly income and education level. Tele-health Usability Questionnaire (TUQ) [16], which is a self-administered online questionnaire with strong content validity, was used as a reference to compose questionnaire of present study. It comprises 18 items to examine patient’s satisfaction level in six aspects: (1) usefulness (items 1-3), (2) ease of use & learn ability (items 4-5), (3) interface quality (items 6-8), (4) interaction quality (items 9-12), (5) reliability (items 13-15), (6) satisfaction and future use (items 16-18). Respondents answered the questionnaire by rating each item based on a 7-point Likert scale, ranging from 1= “totally disagree” to 7= “totally agree”.

Data analysis

      Data from the questionnaires was analyzed using the Statistical Package for Social Scientists (SPSS). For demographics characteristics, categorical variables were evaluated using counts and percentages. Meanwhile, mean, standard deviation, minimum, and maximum were measured for continuous variables. With respect to patient feedback on their virtual visit, average score for each items, each section in TUQ and total average score were calculated.

Demographic analysis

      A total of 150 patients who had attended virtual clinic visits in SUNMED and SMCV participated in the tele-medicine satisfaction survey. Demographic characteristics of respondent are shown in Table 1. Of 150 respondents, 106 (70.7%) are female and 44 (44%) are male. Majority of respondents are Malaysians (n=128, 80%), comprising 20 (13.3%) Malay, 89 (59.3%) Chinese, 8 (5.35%) Indian and 3 (2%) of other ethnicity (categorized as others as in Table 1). Remaining respondents (n=30, 20%) are international patients (non-Malaysian) and their ethnicity are categorized as others (n=30; 20%). Among 150 respondents, 89 (59.3%) are married, 55 (36.67%) are single whereas 6 (4%) are divorced or widowed. Most of them live with their family (n=127, 84.67%), others live with friends (n=10, 6.67%) or live alone (n=13, 8.67%). Occupations of respondents are grouped into professional (n=77, 51.33%), freelancer (n=25, 16.67%), supervisors and manager (n=1, 0.67%), housewife (n=23, 15.33%), student (n=8, 5.3%), unemployed (n=8, 5.3%) and retired (n=8, 5.3%). Monthly income of respondents were gathered in a range of less than Rm 1200 (n=30, 20%), Rm 1200-Rm 5000 (n=62, 41.33 %), Rm 5000-Rm 10000 (n=41, 27.33%) to more than Rm 10000 (n=17, 11.33%). Most of respondent have education level of Bachelor’s Degree (n= 80, 53.33%), followed by diploma (n=30, 20%), Master’s Degree or PhD or higher (n=21; 14%), and secondary school (n=19; 12. 67%).

Patient satisfaction on tele-medicine

      Responses to TUQ questions and average scores are summarized in Table 2 and 3 respectively. According to the responses, respondents were generally satisfied with tele-medicine visit, with average scores for all six aspects higher than 5 and overall average score of 5.72 (Table 3). Usefulness receive highest average score (average score of 6.08). Respondents agreed that tele-medicine provides for their healthcare needs (average score of 5.71), improve access to healthcare services (average score of 6.05) and save their time from travelling (average score of 6.47). Ease of use and learn ability (average score of 5.98), interface quality (overall average score of 5.82) and interaction quality (average score of 5.73) received good satisfaction. Reliability is the least satisfied aspect (average score of 5.10), mainly because visit provided over tele-medicine system is not similar to in-person visit. Nevertheless, tele-health system was perceived as an acceptable and satisfactory healthcare service (average score of 5.70).

Table 1

Table 1: Demographic characteristics of respondents (n=150).

      ^aMedian (Interquartile range) of age.

      ^bRange of age of respondents.

      ^cMalaysian who are of ethnicity other than Malay, Chinese or Indian, and all non-Malaysian.

      ^dDivorced or widowed.

Table 2

Table 2: Feedback of patients on tele-medicine based on TUQ (Frequency).

Table 3

Table 3: Overall feedback of patients on tele-medicine based on TUQ (Mean).

      Although tele-medicine has been employed in many counties, particularly in developed countries, it is not popular in Malaysia. As a result, studies about its implementation, acceptance and clinical impact are limiting. In the settings of COVID-19 pandemic where social distancing and movement restriction are key measures to curb transmission, teleconsultation has been adopted worldwide, including Malaysia, by serving as safe alternative to in-person visit to provide continuous care. As implementation of virtual visit in Malaysia is still new, present study aimed to provide insight into patient feedback of virtual visit during pandemic and movement control as patient satisfaction is mandatory for its further adoption.

      According to TUQ responses, all six aspects received high average score and total average score, indicating that respondents are generally satisfied with virtual visit (Table 3). This finding is consistent with previous studies showing high satisfaction for tele-medicine visits [17-20]. Among the six aspects, usefulness receive highest average score. It demonstrates that virtual visit was able to provide for their healthcare needs, improve access to healthcare services and it was time saving. In fact, time saved from travelling, waiting time, time away from work, and improved access to healthcare services have been frequently reported [21]. Besides, it is noteworthy that one of the contributing factors of positive responses is that COVID-19 pandemic has widely demonstrated usefulness of virtual visit [22].

      It has been pointed out that technology itself acts as one major barrier to tele-medicine adoption [23,24]. To encourage acceptance and facilitate quick setup, the system should be easy to learn and use with good technical support when patients encounter technical difficulties [24]. Here, we show that the ease of use and learnability of teleconsultation system used in present study is high as majority of patients found it simple to use (average score of 5.94) and easy to learn (average score of 6.01). Furthermore, interface quality also received positive responses, patients agreed they had pleasant interaction with system interface (average score of 5.82), they like to use it (average score of 5.71) and found it simple and easy to use (average score of 5.91). Other than having user-friendly system, resolution of video conference is an important factor of high patient satisfaction as low visual or audio resolution has been responded as key distraction by patients [19]. Additionally, patients responded high satisfaction with the interaction quality. They could talk to the clinician easily (average score of 5.87), hear clearly (average score of 5.85), able to express themselves effectively (average score of 5.68) and see the clinician clearly like in-person visit (average score of 5.53).

      Among all aspects, reliability assess if tele-medicine is as reliable as in-person visit received lowest satisfaction. Although error occurred during virtual visit can be fixed easily (average score of 5.29) and solution was provided quickly (average score of 5.13), respondents expressed least agreement to item 13 (visits provided over the tele-medicine system are the same as in-person visits). One possible reason is lack of physical examination, which is one main limitation of tele-medicine frequently responded by patents even though they were generally satisfied with their visit [18]. Indeed, tele-medicine is more applicable for clinical management, diagnostic assessment, and medical decision-making, which require less face-to-face interaction [25]. In line with this, [26]., underlined the necessity of in-person visit despite virtual visit rate increased during pandemic.

      Overall, respondents agreed that tele-health is an acceptable way to receive healthcare services (average score of 5.70).They felt comfortable communicating with the clinician using the tele-medicine system (average score of 5.64) and they are generally satisfied with tele-health system used in present study (average score of 5.72). Therefore, virtual visit received favorable responses from patients.

      Overall, patients were satisfied with their virtual clinic visit and agreed it is an acceptable healthcare delivery. They expressed high satisfaction to usefulness of virtual clinic in improving access to healthcare delivery, provide their medical needs and save the time of travelling. Other than that, they did not experienced much difficulties in learning and using the system and able to have comfortable communication with clinician with good visual and audio quality. Patients reported least agreement that virtual visit provided similar care to in-person visit, but the satisfaction score remains positive.

Future direction

      Although present study demonstrated that patients were satisfied with virtual visit and had satisfactory interaction with clinician, patient-doctor relationship established without face-to-face interaction should be examined, as it is believed that tele-medicine would transform the relationship [27,28]. Moreover, perception of healthcare provider to tele-medicine is another determinant to prompt its integration into medical practice. Another focus of study iscost-effectiveness, as it is one main benefit of tele-medicine by reducing out-of-pocket expenses such as travel expenses, parking, food expenses and potential loss of pay [20,29,30]. In addition, future study should assess the quality of care and health outcome delivered by tele-medicine, whether it show no difference, improvement or negative impact given that different outcomes have been reported [31,32].

Limitation

      One limitation of present study is that present findings isfrom two private medical institutions, Sunmed and SMCV. It does not represent general view of all Malaysians toward teleconsultation. Another limitation is selection bias as only patients who are technological literate and have access to telecommunications technology and internet availability were able to perform tele-medicine visit. Nevertheless, present study showed that patients showed high satisfaction with teleconsultation and agreed that it is an acceptable healthcare service.

      We would like to acknowledge Dr. Eunice Pui Wan Wen for reviewing data analysis. We would also like to thank all participants for their feedbacks.

Funding

      This study was funded by [Sunway Medical Centre research grant SRB/F/20/002].

Conflicts of interest

      The authors have no conflicts of interest to declare that are relevant to the content of this article.

Ethics approval

      Ethical approvals were obtained from the Sunmed Independent Research Ethics Committee, Sunmed and SMCV

Consent to participate

      Informed consent was obtained from all individual participants included in the study.

Consent for publication

      The participantsonsented to the submission of the case report to the journal.

Availability of data and material (data transparency)

      Yes

Code availability (software application or custom code)

      Not applicable

Authors' contributions

      All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by NurulYaqeenMohdEsa, Edwin Tan, Wong Sok Yee and Soo Chun Ian. The first draft of the manuscript was written by Ong Wei Chi and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.