The development of evaluation scale of the patient satisfaction with telemedicine: a systematic review

Background Since the outbreak of the COVID-19 pandemic, telemedicine become more and more popular, patients attempt to use telemedicine to meet personal medical needs. Patient satisfaction is a key indicator of insight into the patient experience. Purpose This systematic review aims to explore the measurement factors of patient satisfaction with telemedicine and develop a more comprehensive and systematic scale of patient satisfaction with telemedicine. Methods In February 2023, a literature search was conducted on the PubMed, EMBASE, and Web of Science, identifying measurement factors and tools of patient satisfaction with telemedicine. For inclusion, the studies had to have or make a questionnaire about patient satisfaction with telemedicine delivered through video/audio visits in English. The quality of the studies was evaluated according to the Critical Appraisal Tool for Analytical Cross-Sectional Studies of the Joanna Briggs Institute (JBI). The dimensions and items in each tool were also analyzed. Results The initial search showed 14,020 studies. After eliminating duplicates and utilizing inclusion and exclusion criteria, 44 studies were included. This systematic review identified and integrated the measurement factors and develops a scale of patient satisfaction with telemedicine, which was divided into 9 dimensions and consists of 37 items. Conclusion Future measurement and evaluation of telemedicine will benefit from scale that was developed in this study, and it will more directly reflecting patient needs when patient satisfaction with telemedicine is evaluated. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-024-02436-z.


Introduction
The World Health Organization (WHO) defines telemedicine as "an interaction between a healthcare provider and a patient when the two are separated by distance", and this communication may be synchronous (as in telephone or video consultations) or asynchronous (when data, queries and responses are exchanged by email or short message service) [1][2][3].Telemedicine could not only provide clinical support and improve health outcomes, but also avoid patient travels, decrease exposure for patients and medical staff, and reduce health sector costs [2][3][4][5].Therefore, It became an essential component of the medical response [6].
During the COVID-19 pandemic, telemedicine played an important role in provision of healthcare services to patients [7].The use of telemedicine delivered through synchronous visits in various countries has increased significantly.At the early stage of pandemic, the weekly telemedicine visits have increased from 12,000 to 1,000,000 in just 3 months in the United States [8].During the isolation period, the remote consultation involving basic medical care has reached 1.2 million people per day in the UK [8].Telemedicine expanded tremendously and continue to flourish [9].In other words, telemedicine has completely changed the medical service mode [10].
Patient satisfaction is one of the most significant indicators reflecting assurance of validation and acceptance of this emerging medical service mode [11].As the voice of the patient, it is the only source of information that can report how they were treated and if the treatment patients received met their expectations [12].With the increasing uptake of telemedicine, it is necessary to insight into what practices and process patients consider to be satisfied with [13].However, Barsom et al. mentioned that different studies used a diverse range of questionnaires to measure patient satisfaction with telemedicine, which resulted in heterogeneous data, so it is difficult to compare and combine results of different studies [14].Agbali et al. concluded that it was necessary to develop a standardized uniform patient satisfaction with telemedicine evaluation tool to increase versatility and agility [15].Therefore, In this systematic review, we aimed to summarized and integrated the relevant measurement factors of patient satisfaction with telemedicine and develop a more comprehensive and systematic patient satisfaction scale for future research use.

Methods
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [16].The protocol was registered with PROSPERO under registration number CRD42022369348.

Study design and search strategy
The retrieval formula consisted of two main parts: "telemedicine" and "satisfaction".Through the two main parts, the following search terms were used: "telemedicine", "telehealth", "telecommunication", "teleconferenc*", "videoconferenc*", "video consultation", and, "satisfaction", "experience", "perception", "preference".Based on the above search terms, we tailored search strategies to each database and used controlled medical subject headings (MeSHs) and search filters where available, or Boolean search methods and free-text terms (Supplementary 1).Due to the outbreak of COVID-19 pandemic, the telemedicine audiovisual mode developed rapidly, and people paid more attention to its satisfaction.During this period, a lot of relevant research appeared, therefore, the search scope for the study was determined from January 2020 to February 2023.

Data sources
A systematic literature search was conducted in the following databases: PubMed, EMBASE, and Web of Science.We also carried out hand searches from reference lists of retrieved studies.

Study selection
The inclusion and exclusion criteria are described in Table 1.Two reviewers screened search results by title and abstract to identify studies whether meet the inclusion criteria outlined above.The full text of potentially eligible studies was retrieved and assessed by the two same reviewers.Any disagreement between them over the eligibility of studies was resolved through discussion with a third reviewer.

Data extraction
The included studies were read in full.Two reviewers performed the relevant information and data that were collated in Microsoft Excel, which includes author, year of publication, country, study design, disease type, telemedicine mode, questionnaire dimension, and the number of satisfaction measurement factors.

Quality and risk of bias assessment
To ensure the validity and credibility of this study, the quality of the included studies was evaluated according to the Critical Appraisal Tool for Analytical Cross-Sectional Studies of the Joanna Briggs Institute (JBI) [9].Quality assessment of the included studies

Study selection
The study selection process and the results of the literature search are depicted in Fig. 1.Using our search strategy, 14,020 studies were retrieved from 3 databases.After removing 2949 duplicates, 11,071 studies were screened by titles and abstracts, and 10,948 studies were excluded.
The remaining 123 studies were read full text, 79 were excluded and finally 44 studies were selected for this study.
Trough the above work, we developed a systematic patient satisfaction scale for telemedicine, involving 9 dimensions and 37 items.It has 36 objective questions and 1 subjective question.The patient satisfaction conceptual framework and scale for telemedicine are displayed in Fig. 3 and Table 3.

Discussion
Our review of 44 studies that assessed patient satisfaction with telemedicine shows that there is minimal agreement on their evaluation tools.As a result, this study makes a comprehensive questionnaire for future research of patient satisfaction with telemedicine.To our knowledge, this is the first systematic review to develop a scale to assess patient satisfaction with telemedicine by a review and integrate of included studies.

Summary of included studies
By observing the characteristics of included studies, we found that most of them were from developed countries, including United States, Italy, Spain, Australia, United Kingdom, Canada and France.Although telemedicine has not been popularized worldwide [64], the patient satisfaction survey could provide a reference for developing and underdeveloped countries.In addition, this study contains a variety of disease types, which shows that the future development of telemedicine is almost unlimited by disease types, and the prospect is extremely bright.As a major role in the development of medical services in the future, telemedicine needs to be continuously improved according to patient satisfaction [65].

Principal findings
In our scale, there was significant variation in the number of reference studies for each dimension (Table 3), 4 dimensions from 20 or more included studies and 3 dimensions from 10 to 20 included studies, while 2 dimension from less than 10 included studies.
According to included studies (n = 23) which relate to the dimension of "diagnosis and treatment result", whether the medical problem and need were overcame are valued.As the initial expectation of patient who use telemedicine, physical condition improvement closely associates with satisfaction [69].To be widely adopted, telemedicine must compete favorably with in-person visits in medical outcomes [70].
A number of included studies has the dimension of "Ease of Use" (n = 19).It mainly includes appropriate system setting and access of services.Ease of use of the technology is an important factor that can influence or even determine the intention to use telemedicine [71].
"System Quality" (n = 25) is the basic factor of telemedicine technology, which may affect telemedicine visits directly and indirectly.On the one hand, audio quality must be of a sufficiently high standard to make effective communication [72].On the other hand, doctor may get vague message with unclear video.This phenomenon could lead patients' treatment delay or diagnostic error.
Based on half of (n = 19) included studies, the usefulness of telemedicine involves various aspects, including saving travel time [73], increasing access to care and doctor [74].In the process of offline medical diagnosis and treatment, patients often encounter the problem of registration difficulties, even the experts.However, the online reservation service of telemedicine can better save the travel time of patients and avoid the situation of making a futile trip.
Although the dimension of "privacy and security" are covered by fewer included studies (n = 8), it is a major obstacle to the adoption of telemedicine.Most patients are accustomed to consider medical quality, and service efficiency as main factors in choosing medical services, which result in the neglect of privacy issues.However, once there was problem about privacy, it will seriously affect patients' impressions and even cause distrust telemedicine.Previous questionnaires nearly did not follow with interest this point [75], our research made up the lack of overlooking the privacy and security.
The dimension of "Overall Satisfaction" is included in most included studies (n = 39), which is used to measure patients' integrated perception.TAM's originators reasoned that the key to increasing use was to first increase acceptance of technology, which could be assessed by asking users about their future intentions to use the technology [76].Therefore, a subjective question that "Expectation of improvement" was included in this dimension.
Multiple digital and telecommunication technologies have created an unprecedented opportunity for the field of health [77].As one of the new technology, telemedicine can offer flexibility and convenience to patients [78].The drivers for satisfaction stem from the benefit of telemedicine [79].According to the above discussion, during the process of researching the patient satisfaction with telemedicine, we not only pay more attention to the significant dimension, but also can we not ignore the issues that have not yet attracted concern and patient's expectation of improvement.These will help providers constantly modify or develop systems widely accepted by users.In a word, the widespread adoption of this scale could help transform telemedicine from a convenience-driven technology into a patient-centered healthcare delivery model.

Limitations
There are 3 limitations in this study.The first limitation is that our research only included three English databases, it may omit valid literatures for our review.The second limitation is that telemedicine is developing rapidly during the COVID-19 pandemic, and its satisfaction measurement factors may be changed in the future.And the last limitation of this study is that this study just research on telemedicine that delivered through video/audio visits.

Conclusion
This review reported on 44 studies that focused on patient satisfaction with telemedicine for various disease.We developed a scale for evaluating patient satisfaction with telemedicine by applying multidimensional constructs to capture patient satisfaction comprehensively, which involves nine dimensions, such as humanistic care, doctorpatient communication, service efficiency, diagnosis and treatment result, ease of use, system quality, usefulness, privacy and security, overall satisfaction.This scale could be a meaningful tool for future studies to delve into patient satisfaction with telemedicine.Not only will it provide researchers with a framework for quantitatively analyzing patient feedback, but also it will give telemedicine providers insights into areas where they can improve their services.And eventually, providers create a truly "patient-centered" telemedicine service to better meet the needs of patient.

Fig. 1
Fig. 1 Flowchart of the selection process

Fig. 3
Fig. 3 Evaluation scale framework for patient satisfaction with telemedicine

Table 1
Inclusion and exclusion criteria

Table 2
Compilation of observations for our sample

Table 2
(continued) The outcome of quality assessmentBased on the Critical Appraisal Tool for Analytical Cross-Sectional Studies of the Joanna Briggs Institute (JBI), 42 studies were at low risk of bias[17-19, 21-44, 46-60],

Table 3
Patient satisfaction scale for telemedicine