This study took place at the Detroit Medical Center (DMC) in Detroit, Michigan. In response to the COVID-19 pandemic, there was a rapid implementation and transition to telemedicine appointments in the outpatient neurology clinic at the DMC from March 18, 2020, when clinics initially shut down, until April 8, 2020, when telemedicine was initiated. This practice serves all patients in neurology, including subspecialties in general neurology, multiple sclerosis, vascular neurology, neuromuscular medicine, epilepsy, movement disorders, neurobehavior and cognitive disorders, and headache. The conversion of all clinics to telemedicine was conducted as part of routine clinical care within the DMC. This patient population had never been exposed to teleneurology at the DMC prior to the implementation during the COVID-19 pandemic. The study’s goal was to determine patient opinion regarding the implementation of telemedicine as well as provider satisfaction with the rapid implementation of telemedicine throughout metro Detroit.

Patients who had at least 1 teleneurology clinic visit from April 1 to December 31, 2020, were asked to complete the survey when they returned to in-person clinic visits. Survey collection occurred from September 2020 to January 2021. All patients, aged 18 years or older, who had a telemedicine clinic evaluation within those dates received the survey after written consent was given. All providers that conducted telemedicine virtual visits after the start of the pandemic received the provider survey. Provider satisfaction surveys were distributed to the Wayne Health practice group, affiliated with the Wayne State University School of Medicine; the DMC Graduate Medical Education office for residents and fellows; and the DMC medical staff organization, which includes staff at the adult central campus hospitals and Children’s Hospital of Michigan. This includes all level of residents, fellows, nurse practitioners, physician assistants, and physicians. Providers who did not participate in a telemedicine consultation were asked to not answer the survey.

The patient surveys were adapted with permission from the Massachusetts’s General Hospital Telehealth Virtual Visit Patient survey [7]. Changes to the survey were made, focusing on the COVID-19 pandemic and infrastructure for telemedicine at our institution. We added demographic questions about age, insurance, transportation requirements, and telehealth experiences, and the layout of the survey was reorganized to reduce the number of printed pages patients had to complete. A Likert satisfaction scale was used to assess the patients’ opinions on the quality of care they received, communication with their provider, technology quality, efficiency, convenience, and their acceptance and willingness to use telemedicine in the future. The surveys were administered to patients in a paper format to be self-completed. Because the survey was administered when the patient returned for an in-person visit, there was no contact or follow-up outside of the appointment regarding the survey.

The technical component of the survey asked questions focusing on where they accessed telemedical care, what device type they used, and the connection type (Wi-Fi, cellular data, etc). Survey questions regarding the virtual visit itself were answered with options of “Yes, Definitely,” “Yes, Somewhat,” “No,” and “Don’t Know.” The second section asked patients about their provider interaction and communication quality differences between in-person versus telehealth visits. The third portion of the patient survey asked patients to compare different types of visits with the options “Virtual Visit is Better,” “Office Visit is Better,” “No Difference,” and “Does Not Apply to Me.” This section finished with a question regarding whether the patient would recommend a virtual visit to family and friends (Section S1 in Multimedia Appendix 1).

The provider surveys were adapted from the Massachusetts’s General Hospital Telehealth Virtual Visit Patient survey [7]. The survey was adapted to a web-based version using our institutional REDCap (Research Electronic Data Capture; Vanderbilt University) site and distributed as an email in September 2021 to all specialty providers, including those in surgery, medicine, and pediatrics [8]. Providers received follow-up reminder emails, and the survey was closed after 3 months. The questions asked were regarding telehealth services provided during the COVID-19 pandemic, with the intention of determining the quality of communication with patients, the technical quality, convenience, and the willingness to incorporate telemedicine into their practice as a permanent feature.

The first portion of the provider survey asked questions about background information such as age, specialty, level of training, and their current experience with virtual visits. Following that, providers were surveyed on a 5-point Likert scale with the options “Strongly agree,” “Somewhat agree,” “Neither agree nor disagree,” “Somewhat disagree,” and “Strongly disagree” to answer more specific questions about their feelings regarding virtual visits (Section S2 in Multimedia Appendix 1).

The Wayne State University Institutional Review Board approved human participant research that can maintain remote study interventions under protocol IRB-20-05-2244. All patients and providers had to consent to participate in the survey. All data received from the survey have been anonymized. Patients and providers were not compensated for their participation in the survey.

The patient survey responses were entered manually from the paper format into the REDCap database. Data were then exported from REDCap into Microsoft Excel, and descriptive statistical analysis was performed. Chi-square tests crossing survey results with patient demographics were performed to look for statistical significance.

Within the examined time period, it is estimated that teleneurology visits were provided to around 1500 patients within the neurology clinic. In total, 117 (7.8%) patients consented to complete part or all of the survey (Table 1). Of the 117 survey respondents, 87.2% (n=102) were aged 18 to 64 years, and 6.8% (n=8) were aged 65 years and older. The majority of patients identified as female (n=78, 66.7%). The most common ethnic or racial group was Black (n=53, 45.5%), followed by White (n=43, 36.8%) and then Hispanic (n=5, 4.3%). Most patients reported an education level of completing high school or higher (n=96, 82.1%). Six neurology subspecialties were represented, with most patients being seen in epilepsy (n=59, 50.4%) and multiple sclerosis (n=33, 28.2%) clinics.

A total of 84 (71.8%) of the patients’ telemedicine visits were follow-ups. Audio or video connection was the most common type of visit (n=60, 51.3%), followed by audio- or telephone-only visits (n=45, 38.5%); the rest did not respond to the survey question. Furthermore, 91 (77.8%) patients reported that they had to miss an appointment in the last year before the COVID-19 pandemic due to issues with transportation. Two-thirds (n=74, 63.2%) of patients relied on transportation from family and friends (n=56, 47.9%), medical transportation (n=12, 10.3%), or public transportation (n=6, 5.1%) in the year prior to their teleneurology visits.

Finally, 75.2% (n=88) of patients used their own cellphones to conduct their teleneurology visit. Patients most commonly used a Wi-Fi network (n=64, 54.7%) or cellular data (n=33, 28.2%) to connect to their visits. Only 20 (17.1%) reported issues during those visits, mostly with connection issues or audio or visual connection issues. Despite these issues, 59.8% (n=70) noted they were still able to complete their visit.

Overall, 87 (74.4%) patients rated their experience with their teleneurology visit as 8 out of 10 or higher, with 10 being the “best visit.” Moreover, 88 (75.2%) patients stated that they would recommend a virtual visit to their family and friends. A substantial majority of patients reported satisfaction with the time spent with their provider. In terms of convenience, 42.2% (n=49) of patients noted that a virtual visit was better for finding time for appointments, and 49.1% (n=57) felt time saved from traveling was better with virtual appointments (Multimedia Appendix 2). Despite satisfaction with virtual visits, 58.1% (n=68) of patients felt that office visits grant better ability to show their physician a physical problem, and 37.6% (n=44) stated that office visits were better for a personal connection with their physician. A significant relationship between racial or ethnic group and comfort sharing private info was found (P<.001), with 52% (26/50) of Black patients reporting that an office visit was better, compared to 25% (14/52) of non-Black patients.

A total of 40 providers responded to the provider survey, 4 (10%) of which were nurse practitioner or physician assistants, 21 (52%) were physicians, and 15 (38%) were residents or fellows (Table 2). Providers were mostly female (n=26, 65%) and between the ages 30-39 years (n=19, 48%). Nearly half (n=19, 48%) practiced in a setting that is 75% to 100% outpatient.

At the time of the survey, 13 (32%) providers indicated that they had completed over 100 virtual visits. A fifth (n=8, 20%) of the providers performed virtual visits exclusively with audio and video input, whereas 13 (32%) of them indicated that 75% or more of their virtual visits were via audio or telephone only. About half (n=23, 58%) of the providers exclusively conducted virtual visits at their clinic or office, and the other half (n=17, 42%) preferred to work purely from home or a mix between home and office.

Overall, 80% (n=32) of providers reported little or no technical issues. The most common applications to connect were the Doximity dialer application (n=13, 32%) and Zoom (Zoom Video Communications; n=9, 22%). A total of 75% (n=30) of providers described the processes of setting up their telemedicine station and acclimating to their application of choice as easy, and 48% (n=19) of them felt that after 1 or 2 virtual visits, they were comfortable with the technology. The top 3 problems encountered by providers during their virtual visits were issues with remaining connected, hearing or being heard, and seeing or being seen.

Overall, 75% (n=30) of providers agreed that virtual visits are a valuable tool to enhance patient care, and 70% (n=28) would recommend a virtual visit to their family members or friends. Furthermore, 25 (62%) respondents agreed that telemedicine offers an effective replacement for follow-up appointments, and in terms of efficiency, 42% (n=17) thought virtual visits were better (Multimedia Appendix 3). However, the majority of providers (23/40, 57%) enjoyed in-person visits more than virtual ones, and they overwhelmingly agreed that office visits were better for seeing physical problems (Figure 1). Of the 15 trainee physicians who responded, 9 (60%) agree that they would miss video visits if they were no longer an option and 3 (20%) were indifferent, whereas 13 (62%) of the 21 physicians on faculty would miss video visits and 3 (14%) reported indifference. Interestingly, while half (20/40, 50%) stated that office visits were better for developing a personal connection with their patients, 42% (n=17) noted they felt no difference with the appointment modalities. Lastly, fewer than 40% (n=15) of providers agreed that they understood the compensation model for virtual video visits.