New York City was the world’s COVID-19 epicenter in early 2020 [1]. As of May 8, 2020, the five boroughs had 175,997 confirmed cases and 14,381 deaths, comprising 14% of all confirmed cases and 19% of all deaths from COVID-19 in the United States [2]. Health care providers postponed elective surgeries, expanded intensive care unit (ICU) capacity, deployed nursing and physician staff, and rapidly transitioned most clinic encounters to telemedicine (defined here as synchronous video visits) [3].

Historically, telemedicine focused on rural medicine [4] and/or moved forward incrementally through institutional initiatives [5]. The widespread adoption of telemedicine associated with the COVID-19 pandemic was unprecedented and may have a significant and durable impact on health care delivery. Telemedicine has not commonly been tested in disaster settings [6]. It was an essential component of the medical response to COVID-19 by reducing demand on strained health care infrastructure and enabling health care needs to be met at home while reducing exposure for patients and medical staff [7,8]. Patient demand for telemedicine outstripped the ability of health care providers to supply it [9]. In early March, the Centers for Medicare and Medicaid Services established telemedicine payment parity with in-person visits, suspended licensure and malpractice insurance restrictions, and waived HIPAA (Health Insurance Portability and Accountability Act) regulations regarding video visits [10] to limit barriers to widespread adoption of telemedicine.

We examined patient acceptance of video visits by comparing Press Ganey patient satisfaction scores for video vs in-person visits at an urban, quaternary referral, academic medical center from April 1, 2019, to March 31, 2020. We hypothesized that there would be no difference in Press Ganey patient satisfaction scores between video and in-person visits. We captured one month of clinic visits during the COVID-19 pandemic and sought to determine the factors associated with patient satisfaction during this time frame.

NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCM) is a large nonprofit academic medical center located in New York City. As of May 8, 2020, NYP/WCM has admitted a total of 1443 COVID-19 patients. At our institution, inpatient services are provided at NYP, while outpatient services are provided predominately at WCM facilities; both institutions share the same providers.

NYP/WCM experienced an 8729% increase in video visit use during the COVID-19 period compared to the pre–COVID-19 period.

The mean age of the total study population was 58.8 years (SD 16.5 years). Patients were slightly older in the pre–COVID-19 period than COVID-19 period (59.85 years vs 59.08 years; P=.03) (Table 1). There were no differences in gender or other visit characteristics between the two time periods.

In the pre–COVID-19 period, very few outpatient visits types were video visits (0.3%). During the COVID-19 period, video visits comprised 21.9% of outpatient visits. The proportion of all in-person visit types decreased except for postoperative visits. The visit type “follow-up” showed the greatest decline in share of outpatient visits, decreasing from 50.0% to 36.5% over the past year. Internal medicine outpatient visits constituted the greatest proportion of visits in both time periods.

Press Ganey patient satisfaction scores were significantly higher in the COVID-19 period when compared to the pre–COVID-19 period (93.4% vs 92.5%, P<.001). Notably, across the study period, patient satisfaction with video was significantly higher than in-person visits (94.9% vs 92.5%, P<.001) (Figure 2); this association was consistent during the pre–COVID-19 (95.0% vs 92.5%, P<.001) and COVID-19 periods (94.9% vs 93.0%, P<.001). While Press Ganey scores with video visits did not change across time periods (95.0% vs 94.9%, P=.31), the scores for in-person visits increased in the COVID-19 period (92.5% vs 93.0%, P=.004).

Overall, all of our covariables were statistically significant (Table 2). In adjusted analyses, video visits (parameter estimate [PE] 2.18; 95% CI 1.20-3.16), the COVID-19 period (PE 0.55; 95% CI 0.04-1.06), and the age category 60-79 years (PE 0.70; 95% CI 0.29-1.11) were associated with higher Press Ganey scores. Female gender (PE –0.73; 95% CI –0.96 to –0.50) and new visit type (PE –0.75; 95% CI –1.00 to –0.49) were associated with lower Press Ganey satisfaction scores.

Traditionally, health care encounters between a provider and a patient have occurred face to face in a physical location. Over the past 20 years, the internet and technology have made it possible for health care to be delivered digitally, providing new avenues for medicine to improve the value of care. Bridging gaps in time and distance, video visits have enabled providers to remotely care for patients with acute stroke [5], requiring intensive care [12], and located in rural areas or prison [13]. Half the hospitals in the United States report providing telehealth-based services [14]. Two years ago, the concept of a “medical virtualist” was created to describe a new specialty in which physicians primarily deliver care digitally [15]. The strengths of telemedicine have made it an indispensable tool in the clinical response to the COVID-19 pandemic. With the removal of financial disincentives and privacy barriers that limited widespread adoption, use of telemedicine has grown substantially in the United States during the COVID-19 pandemic. The 8729% increase in video visit utilization at our academic medical center is akin to the 4345% increase at New York University Langone Health [16] and the 4000% increase at Partners Healthcare [17].

Telemedicine is a new, and potentially disruptive, innovation and must be shown to be safe, effective, patient-centered, timely, efficient, and equitable [18]. Clinical consultations conducted through video visits are associated with high patient satisfaction [19,20] and lower costs [21-23] without a difference in clinical outcomes [13,24-27] compared to in-person consultations. However, most of these conclusions are based on evidence from small studies focused on remote telemedicine in sparsely populated locations or highly specific patient populations (eg, stroke care, rural ICUs, prisons) [5,12,13] not relevant to the care delivered during the COVID-19 pandemic [28]. Of all studies evaluating quality in telemedicine, four systematic reviews demonstrate there is limited published evidence to evaluate patient satisfaction as a metric for comparison to in-person visits [29-32]. This is problematic because patient satisfaction has been cited as the most important factor in the success of telemedicine initiatives [33]. Patient satisfaction as a measure of quality of care is a valid outcome [34] and a key component to value-based care [35]. Patient satisfaction is also associated with treatment plan adherence [36], reduced surgical readmissions [37], and patient retention [38].

Using the most current Press Ganey satisfaction scores, we found that video visits were associated with greater patient satisfaction when compared to in-person visits, which was not what we initially hypothesized. However, our results do not justify the use of telemedicine in lieu of in-person visits if both were equally accessible given the limitations outlined below. Furthermore, we observed that overall patient satisfaction is higher in the COVID-19 period, and that younger age, female gender, and new visit type were associated with lower patient satisfaction. To our knowledge, this is the largest study of patient satisfaction comparing video to in-person visits. The results of our study have particular relevance due to the unprecedented public health crisis that has necessitated the widespread adoption of video visits for patient safety and practicality.

Our study must be interpreted in the context of the study design. First, this is a retrospective study that prevents us from establishing causality between video visits and increased patient satisfaction. However, our data captures a rapid transition of outpatient care to video visits associated with the COVID-19 pandemic, and our analysis was adjusted for time. Second, our deidentified data did not capture patient-level variables that may influence Press Ganey scores, such as race, income, education, comorbidities, and other characteristics as they were not reported to WCM by Press Ganey to maintain patient confidentiality. Third, the same Press Ganey survey items were used for both video and in-person visits even though Press Ganey developed a new telemedicine version of the Medical Practice Survey in 2018 that may better characterize unique aspects pertinent to video visits [39]. Fourth, we were unable to assess for nonresponder bias; respondents to Press Ganey surveys have been shown to be more satisfied and more willing to respond than nonrespondents [40]. Fifth, what constitutes a clinically significant difference in patient satisfaction using Press Ganey survey scores is not well established. However, that said, there is mounting evidence in recent years that Press Ganey patient satisfaction score increases of 1%-10% can be viewed as clinically relevant [41-44].

In conclusion, we demonstrate that patient satisfaction with video visits compared favorably with in-person visits over the past year and during the COVID-19 pandemic. Our findings support the use of video visits as a viable alternative to traditional in-person visits. The New York City experience may offer insights into the future use of video visits as a new paradigm for health care delivery generally and in times of public health crisis.