Background

The World Health Organization (WHO) on March 11, 2020, declared coronavirus infectious disease 2019 caused by SARS CoV-2 virus infection, as a global pandemic that would affect all countries of the world [1]. The lack of specific treatments forced governments to focus on preventive strategies, such as lockdowns, social distancing, and quarantine which have been adopted to reduce viral transmission [2]. Due to the COVID-19 pandemic, healthcare organizations had to face challenging circumstances and modify the usual modality of service provision and introduce telehealth services in their routine patient care to lessen the risk of direct human-to-human exposure [3]. Patients expressed concerns about personal visits to healthcare units and the possibility of obtaining telemedicine turned out to be an effective tool for the continuity of care [4, 5]. Telemedicine had been gradually implemented for approximately a decade, and the COVID-19 pandemic resulted in a large-scale expansion of telemedicine use throughout healthcare facilities and primary care practices all over the world [6, 7].

The most common definition of telemedicine is provided by the World Health Organization WHO: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities [8]. In Poland, telemedicine is a relatively new healthcare delivery tool.

The report published at the turn of 2016 and 2017 indicated that only 7% of the Poland population (out of 38.5 million) uses medical services via the Internet. The average in the European Union countries is 13%. The report indicated that 98% of the population has no concerns about e-privacy, and 48% of the population seeks information about their health via the Internet [9]. According to the data for 2018, collected by Statistics Poland, 83% of all Polish households had broadband internet access at home. This has grown to 92,6% in 2022 due to the COVID-19 pandemic [10].

In order to develop the digitalization of the health sector in Poland, many projects supervised by the Minister of Health were adopted and successively implemented.

The first project implemented in 2018 ‘Electronic Platform for Collection, Analysis and Sharing of Digital Resources on Medical Occurrences’ provide the possibility of issuing and using e-prescriptions and e-referrals, and introduced the Patient Internet Account (IKP). By setting up an account with IKP and then logging in, patients have access to their medical records. The next project, Electronic Medical Records (EDM) involved the digitalization of medical records in accordance with the CDA HL 7 standard. EDM include information on diagnosis, results, recommendations or refusals of admission to hospital, e-prescriptions and e-referrals, as well as an information card covering the entire process of inpatient treatment [11]. ‘Improving the quality of management in healthcare by the popularization of knowledge about ICT’ was an educational project completed in 2015, in which employees acquire adequate professional knowledge of the use of modern technologies in the workplace [11]. The aim of the ‘Reducing social inequalities in health through the use of telemedicine and e-health solutions’ telemedicine project was to reduce the costs of medical procedures and facilitate access to medical services for patients in several areas of medicine: cardiology, geriatrics, obstetrics, palliative care, chronic diseases, diabetes, and psychiatry [11].

Legally providing healthcare services remotely started to be possible at the end of 2015 pursuant to Article 3, paragraph 1 of the Act on Medical Activity [12]. Although telemedicine visits were introduced into the system within primary care on 5 November 2019 by decree of the Minister of Health, the actual number of remote consultations between physicians and patients was rather low [13]. The announcement of the state of the COVID-19 pandemic and the need to provide health services safely for the patient and medical staff resulted in telemedicine being implemented in March 2020 on a large scale in primary health care [14]. In March 2021, the Ministry of Health issued a legal act regulating telemedicine visits. Primary care physicians could not refuse a face-to-face visit to a patient who refused remote consultations and had no suspicion of a COVID-19 infection. According to the report published in July 2020, by the Polish National Health Fund, more than 80% of all visits to primary care physicians from the beginning of the COVID-19 pandemic were carried out remotely, mainly by telephone [14]. The vast majority of patients experienced telemedicine consultations for the first time.

In 2021, the Polish National Health Fund introduced the First Contact Teleplatform with one toll-free number for the citizens of the entire country. Medical advice is provided not only in Polish but also in English, Ukrainian, and Russian, as well as in sign language via video chat. The services of the First Contact Teleplatform can be used outside the working hours of primary healthcare facilities. [15] The view that telemedicine is the future of primary health care was well established before the pandemic, however, it was greatly enhanced by the considerable benefits revealed during the COVID-19 era [16, 17]. The importance of telemedicine in primary care extends beyond the COVID-19 pandemic. It provides convenient access to healthcare, especially for those with limited in-person options. This accessibility bridges healthcare gaps, ensuring a wider population can receive timely medical guidance. 61,9% of all Polish patients received a teleconsultation in 2020 and 2021, which was considerably higher than the EU average of 39%. This is the 3rd highest number in Europe (after Spain and Slovenia) [18]. In 2022, 23.5 million teleconsultations were performed in primary medical care and 10.6 million in specialist care [19]. What is noteworthy, there is a fundamental shortage of doctors in Poland, which has 3,44 practicing doctors per 1000 inhabitants and remains one of the lowest among EU countries [20]. This has an impact on the accessibility of care, mainly in more rural regions. In 2020, 1.9% of the Polish population reported unmet needs for medical examinations due to either costs, distance, or waiting times (the EU average was 1.8%) [21]. Telemedicine facilitates continuous care, monitoring chronic conditions, managing medications, and promoting preventive measures, all while offering convenience. Some 39% of Polish adults reported having at least one chronic disease in 2019 –a slightly higher proportion than across the EU as a whole (36%) [21]. Ongoing technological advancements are improving the quality of telemedicine services, making teleconsultations more interactive and informative.

Nevertheless, the effective implementation of telemedicine into primary health care, particular areas such as patients’ experiences needs to be investigated further. Patient experiences are the main factor determining how healthcare meets the patients’ needs, and directly leads to improvements in healthcare services [22, 23]. In the literature, patients’ perceptions of telemedicine are often used as a measurement of patient satisfaction [24]. The importance of patient satisfaction is further demonstrated as fundamental in patient-centered care, which directly improves patients’ outcomes [25, 26]. Patient satisfaction is a complex and difficult concept that requires further elucidation [27].

Due to the limited experience with telemedicine before the COVID-19 pandemic in Poland, we sought to fill this gap by studying the experiences of Polish patients. The aim of our study was to understand how patients define satisfaction and dissatisfaction with telemedicine during the COVID-19 pandemic in primary care.

Material and methods

Measurements

Individual, telephone semi-structured interviews were carried out according to an interview guide. The interview topic guide included the questions listed in Table 1 below.

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Table 1. Questions included in the interview topic guide.

https://doi.org/10.1371/journal.pone.0293089.t001

The telephone interviews were performed at a time convenient for each participant. All interviews were audio recorded and then transcribed verbatim. All the interviews were conducted in Polish by the same interviewer (KP). There were no repeat interviews.

Results

Table 2 below displays the characteristics of the individuals who took part in the study. The participants (n = 20) were between 26 and 74 years old (the average age was 42 years); there were 15 females and 5 males. Five participants had secondary education, ten higher education, and five vocational education. All the participants were of Polish nationality.

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Table 2. Characteristics of participants (n = 20).

https://doi.org/10.1371/journal.pone.0293089.t002

The analysis of the content of the transcripts identified the following categories related to how patients understand satisfaction or dissatisfaction with telemedicine: (1) health improvement, (2) opportunity to express patients’ concerns, (3) ensuring continuity of care, (4) the doctor-patient relationship, (5) follow-up consultation, (6) convenience, (7) lack of physician’s involvement in conducting telemedicine, (8) leaving patients unsupported, (9) misdiagnosis (Table 3).

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Table 3. Categories and subcategories (interview number).

https://doi.org/10.1371/journal.pone.0293089.t003

Discussion

This qualitative research reported patients’ experience with telemedicine in primary care settings in the Podlaskie Voivodeship during the COVID-19 pandemic. The main objective was to comprehend the patients’ understanding of satisfaction with telemedicine. In our study, the majority of participants responded positively to switching to remote consultations in primary care, which was consistent with the research conducted by The Ministry of Health [14].

The qualitative study, conducted before the COVID-19 pandemic, established the following ways of understanding patients’ satisfaction with the care provided by family doctors during face-to-face visits, i.e. good doctor-patient interaction, health improvement, fulfillment of prior expectations, and availability of care [27]. Although the results of the qualitative research were difficult to compare, some topics were common and overlapped. In our research, satisfaction with telemedicine in primary care was defined as health improvement resulting from telemedicine consultation, ensuring continuity of medical care, and the opportunity to express one’s concerns. The participants also paid attention to the established doctor-patient relationship.

Pre-pandemic studies on telemedicine utilization among primary care facilities were limited. The research revealed that patients’ satisfaction with telemedicine was related to convenience and improved access to medical care, which was also indicated in our study [31–35]. The increased access to medical services compared to face-to-face visits enables a more prompt response to patients’ needs and allows for consulting a greater number of patients [36, 37]. The convenience of telemedicine consultation, in terms of saving time, and reducing stress, travel, or employment disruption, may indirectly improve access for individuals with previously low engagement in healthcare [34]. Furthermore, telemedicine creates more equitable access to medical care for those finding face-to-face visits difficult, e.g. people with disabilities or difficulties with arriving at the clinic. It should be emphasized that due to the fact that young patients may overuse telemedicine and certain age groups may need more assistance in participating in a telemedicine consultation, elderly patients may not be able to benefit from telehealth. In the mentioned scenario, telemedicine may even reduce access to medical care.

From the participants’ perspective, satisfaction with telemedicine was associated with receiving enough space to express their concerns. Our study confirmed the reports by other authors, that the most significant aspect was receiving telemedicine consultation without the pressure of time, in which patients felt reassured and heard [36]. Some patients indicated that the quality of care during telemedicine consultation did not differ from a face-to-face visit [35, 38]. In previously conducted studies, patients described telemedicine visits to be more personal and focused, and they felt more comfortable communicating during a remote encounter [37]. As a result of telemedicine, the relationship between doctor and patient grows into a more intimate, closer connection regardless of physical distance [39]. In line with the body of research, patients’ satisfaction with telemedicine was built on established relationships with their primary care physicians [35–39]. The participants reported that they trusted their primary care physicians and felt comfortable during telemedicine consultations [35]. From the participants’ perspective, connecting with a known, trusted doctor was more significant than having a face-to-face visit with an unfamiliar physician. A few patients contradicted these findings and emphasized the insufficient involvement of physicians and lack of empathy during remote consultations, which was particularly important during the COVID-19 pandemic. In the participants’ opinion, they were left alone in the face of a new phenomenon that caused great fear. They described concerns about being overlooked during telemedicine visits as they felt the approach was intended to prevent patients from having face-to-face consultations. Therefore, in order to prevent patients from feeling overlooked, physicians should demonstrate an understanding of the patient’s medical ailments and clearly explain why a face-to-face consultation is not suitable in those particular cases. Those impersonal consultations were also related to the lack of an established patient-doctor relationship [37]. On the other hand, in the previous study, even when the pre-existing patient-doctor relationship had not been established, telemedicine visits could still prove to be successful if the physicians built a rapport with their patients [36]. Providing ‘evidence-based’, compassionate care with shared decision making contributes to a strong physician–patient relationship which should be the main goal of primary care. It is clear that specific communication skills are required for doctors in the environment of telemedicine consultations to provide patient-centered care [40].

In our study, the participants described satisfaction as the effectiveness of their treatment. The sense of health safety among many participants was largely ensured by taking an in-depth medical history. In line with the body of research, it was emphasized that rather than implementing telemedicine consultations for all consultations, a particular focus should be placed on minor conditions where, according to the patients, a physical examination was not required [37]. The participants emphasized that in the event of unknown or unstable conditions, they would prefer to be seen in person and receive a physical examination. In particular cases, the patients found the lack of physical interaction would negatively affect the care received during a telemedicine visit [34]. However, the effects of the lack of face-to-face interaction could be mitigated by using video consultations rather than relying on audio as the only form of telemedicine [34]. Additionally, it was found that participants believed that telemedicine enables physicians to decide if patients require a face-to-face visit, which may reduce unnecessary in-person consultations in primary care [34].

Conclusion

The results of the study revealed patients’ in-depth perception of telemedicine. They are also a substantive summary of the implementation period of telemedicine in primary health care during the COVID-19 pandemic. In our research telemedicine met with a positive reception and was recognized by the majority of patients who had experience with it as a valuable channel of contact with a primary care physician. In order to increase the level of patient satisfaction, the focus should be on improving aspects such as physician engagement and showing empathy during telemedicine, as well as providing a full, exhaustive explanation of the treatment process. It is important to provide face-to-face visits when telemedicine consultation does not produce the expected result or if that is the patient’s preference. Respecting patient needs and preferences while performing telemedicine visits is the goal of patient-centered care. Further research into patient perceptions and experience with telemedicine in primary care outside the COVID-19 pandemic using qualitative research is required to reveal how patients’ perceptions change over time. This will lead to improvement in patient satisfaction and patient-centered care and will enable the implementation of further modern telemedicine solutions in primary care.

Supporting information