In the early days of the coronavirus disease 2019 (COVID-19) pandemic, telemedicine was recommended as a solution to provide safe access to healthcare.1 In 2020, the World Health Organization reported that most global health authorities regarded telemedicine as a potential method to provide services for patients with non-communicable diseases.2 For example, in a national survey of healthcare providers in Germany, approximately 60% of participants reported routine or partial use of telemedicine during the COVID-19 pandemic.3 In the US in 2020, telemedicine was used for COVID-19 screening, monitoring of patients with positive COVID-19 test results, management of chronic diseases, and virtual monitoring and follow-up.4 Telemedicine reduces patient travel costs and improves access, while reducing the use of personal protective equipment and the risk of COVID-19 transmission. In China, ‘internet hospitals’ offered essential medical support to the public during the early days of the COVID-19 pandemic.5

However, from a patient perspective, there are limitations and barriers to the use of telemedicine. A qualitative study conducted in Hong Kong in 20166 revealed that patient concerns included technical and logistical issues (eg, difficulty in accessing and using computers), limited personal interactions (eg, lack of in-person physical examinations and risk of incorrect diagnosis related to poor communication), concerns regarding cybersecurity and safety, and problems with prescriptions (eg, distrust of local community pharmacies). In 2020, clinical guidelines were published concerning the performance of remote primary care assessments and treatments for patients with suspected COVID-19 in the United Kingdom.7 During the COVID-19 pandemic, a digital health ecosystem may benefit the healthcare system, as well as the broader population (eg, through tracking and communication strategies) and research and health technology sectors (eg, online activity monitoring and digital support for isolation and quarantine situations).8

Telemedicine consists of remote healthcare service delivery by healthcare professionals for diagnosis, treatment, and prevention efforts, as well as research and continuing education.9 The fundamental goal of telemedicine is to increase access to care, thereby serving populations that otherwise would not receive timely medical evaluation and treatment. Research concerning telemedicine effectiveness has been controversial.10 11 12 13 14 A previous systematic review found that many studies showed no difference between telemedicine and usual care, and there remains limited evidence concerning the cost-effectiveness of telemedicine.10 With respect to chronic disease management via telemedicine, another review found publication bias and a tendency to report only short-term outcomes.11 Moreover, a Cochrane review revealed improved control of blood glucose among patients with diabetes using telemedicine, compared with patients receiving in-person care; conversely, the care modality did not affect health outcomes among patients with heart failure.12 Regarding the impacts and costs of telemedicine services, economic analyses have been problematic because of complex and unpredictable collaborative achievement processes13; generalisability has been limited by poor quality and low reporting standards.14 There is a need to focus on patient perspectives and telemedicine innovations.

In 2020, the health system in Hong Kong was considerably impacted by COVID-19 transmission risk and public health responses.15 During the early days of the COVID-19 pandemic, the number of in-person medical consultations decreased worldwide.16 17 In the Netherlands, the use of telemedicine offset this decrease.17 Before the COVID-19 pandemic, telemedicine was not widely used in Hong Kong6 18; user perspectives concerning the role of telemedicine during the COVID-19 pandemic and future pandemics require investigation. This study of telemedicine users in Hong Kong explored their perceptions of telemedicine use during the COVID-19 pandemic, their perceptions of disease risk, and their COVID-19 preparedness measures. We hypothesised that telemedicine users have distinct perceptions of risk, compared with the general public; we sought to determine the effects of such differences on the delivery of health services.

We conducted a cross-sectional online survey from 6 April to 11 May 2020. Participants in this study were users of COVID-19 testing services provided by The Chinese University of Hong Kong (CUHK) Medical Clinic,19 a multispecialty clinic offering specialist consultations, health screenings, vaccinations, and COVID-19 testing services.

All service users completed a telemedicine consultation, followed by COVID-19 testing. The consultation, delivered using a standard telephone, focused on assessment of the user’s COVID-19 risk prior to the time of testing. Users were offered a deep throat saliva test for COVID-19 detection. After the telemedicine consultation and COVID-19 test, all users were invited to complete an anonymous online survey within 1 month for service evaluation and data collection.

The online survey consisted of 24 questions regarding telemedicine services, COVID-19 risk perception, and preparedness measures in Hong Kong. The survey specifically focused on reasons for using CUHK telemedicine and testing services, user perceptions and attitudes regarding telemedicine consultations, user perceptions and attitudes regarding the COVID-19 pandemic and prevention, and user characteristics (eg, age and sex). Questions about user perceptions and attitudes regarding the current COVID-19 pandemic and prevention were phrased in a manner identical to a previous study,20 allowing direct comparison with survey results from a study focused on the Hong Kong general public. The survey was pilot tested and subsequently modified to ensure content validity. Most questions included ‘yes’ or ‘no’ answers and a 5-point Likert scale. Written consent to take part in the study was obtained from all participants before they began the survey.

Descriptive statistics were reported for participant characteristics, perceptions, and attitudes regarding telemedicine consultations. Perceptions and attitudes regarding the COVID-19 pandemic and prevention were recorded in a manner that allowed comparison with the results of a prior COVID-19–focused telephone survey of the Hong Kong general public.20 The prior telephone survey—a cross-sectional, population-based landline telephone survey using a computerised random-digit dialling method—included 765 adult Hong Kong residents during the period from 22 March to 1 April 2020. The participants in that study were representative of Hong Kong Census population data with respect to age, sex, marital status, and residential district, although they had higher levels of education and household income.20 Chi squared tests were used for comparisons between the prior survey and the present survey. The threshold of statistical significance was set at 0.05. All statistical analyses were conducted using SPSS (Windows version 21.0; IBM Corp, Armonk [NY], US).

Among 187 telemedicine users of COVID-19 testing services at the CUHK Medical Clinic, we identified 150 responses to the online survey during the period from 6 April to 11 May 2020. In total, 141 telemedicine users (response rate of 75.4%) were willing to participate in this study. Table 1 shows the participants’ characteristics. Notably, 56.1% were men, over half (50.7%) were aged 18 to 24 years (all participants were aged <65 years), most (59.4%) lived in private housing, and most (65.4%) resided in the New Territories. The most common reason for COVID-19 testing was a work-related requirement (56.7%, 80/141), followed by recent international travel (39.7%, 56/141); 14.9% (21/141) of the participants sought testing because of concerns about the spread of COVID-19. Overall, 14.2% (20/141) of the participants had either been in close contact with a confirmed case or suspected that they had symptoms of COVID-19.

In total, 95.1% (116/122) participants believed that COVID-19 telemedicine consultations were useful. Most participants believed that telemedicine consultations could perform the functions of ‘health protection, promotion and disease prevention’ (73.6%) and ‘diagnosis’ (64.0%) [Fig 1]. Concerning the choice of telemedicine provider, almost all participants (99.2%) would accept medical doctors; more than half of the participants (54.1%) would accept trained nurses, but only 13.1% would accept non-clinical staff who had been trained to provide telemedicine services.

Nearly half of the participants (49.0%) agreed or strongly agreed that telemedicine consultations were appropriate during the COVID-19 pandemic (Fig 2). More than half (61.0%) of the participants reported satisfaction with telemedicine consultations (‘agree’ or ‘strongly agree’) and services provided by clinic staff (73.8% responded ‘agree’ or ‘strongly agree’). However, only 36.2% agreed or strongly agreed that service quality was identical between telemedicine consultations and in-person consultations.

Household capacities for potential COVID-19—related quarantine were compared between telemedicine users in this study and respondents in the prior Hong Kong general public telephone survey20 (Table 2). Telemedicine users reported having less space at home, fewer masks, fewer gloves, and less detergent for potential quarantine situations, compared with respondents in the Hong Kong general public telephone survey (all P<0.05).

In response to the question ‘How many designated caregivers are appropriate for each isolated/quarantined person?’, telemedicine users were less likely to answer correctly (limit to one main carer, 8.1%), compared with respondents in the Hong Kong general public telephone survey (51.3%)20 [P<0.001, Chi squared with continuity correction].

Most telemedicine users (76.4%) believed that household prevention could prevent COVID-19; approximately 67% of them believed that they had sufficient knowledge to manage COVID-19—related health risks. These percentages were higher than the percentages in the Hong Kong general public telephone survey20 (Table 3). Additionally, >80% of telemedicine users believed that Hong Kong had achieved better control of COVID-19, compared with other major cities.

Regarding their main channel for infectious disease information, approximately 64% of participants were using the internet or mobile applications, whereas 24% were using television; these percentages differed from the Hong Kong general public telephone survey, in which 56.5% of respondents used the internet or mobile applications and 36.2% used television20 (P<0.001). Overall, telemedicine users preferred their main channel for infectious disease information to be the internet or mobile applications and personal sources (eg, family, friends, or healthcare professionals).

This study demonstrated high satisfaction with telemedicine consultations among users and revealed that users considered telemedicine to be appropriate during the COVID-19 pandemic. Despite the perception that telemedicine users have sufficient knowledge to manage health risks from COVID-19, when responses were compared between telemedicine users and the Hong Kong general public, we found that household preventative measures were inadequate among telemedicine users.

Most of our telemedicine users did not agree that quality was identical between telemedicine consultations and in-person consultations. This perspective possibly resulted from the provision of telemedicine consultations via telephone without a video component; moreover, the users might not have been familiar with the concept of telemedicine consultation. Indeed, a 2014 nationwide survey in the US revealed that only 15% of family physicians reported using telemedicine in the previous year; barriers included a lack of training, a lack of reimbursement, the cost of equipment, and potential liability issues.21 Furthermore, Schwamm22 has described telemedicine as a disruptive technology that may threaten traditional healthcare delivery. Obstacles to the expansion of telemedicine in the US include state-level statutes that require the clinician to be located in the same state as the patient and to have previously completed an in-person consultation with that patient.23 Similar regulatory requirements exist in Hong Kong.24

Various studies in the US have detected increasing uptake of telemedicine, particularly in primary care.25 26 27 28 29 A study of telemedicine users in a large commercially insured population in the US from 2005 to 2017 showed that the mean age was 38.3 years; on average, users of primary care telemedicine were younger than users of telemental healthcare and more likely to reside in urban areas.25 A study regarding Teladoc, one of the largest telemedicine providers in the US, revealed that Teladoc users were younger and less likely to have used healthcare before the introduction of Teladoc; they were also less likely to have a follow-up visit in any setting, compared with patients who visited a clinic for a similar condition.26 These findings are consistent with our observations that most telemedicine users were young; they also suggest that the use of telemedicine services can provide opportunities for healthcare access that are not otherwise available.

Intriguingly, although more telemedicine users agreed that household preparation could prevent COVID-19, they were less likely to believe that their household preventative measures were adequate, compared with respondents in the Hong Kong general public telephone survey.20 This disparity may be attributed to differences in participant characteristics: telemedicine users in this study were younger (51% aged 18-24 years, vs 9% in the Hong Kong general public20), were male (56% vs 47%20), and were living in the New Territories (65% vs 51%20). Telemedicine users were also more likely to use the internet (64% vs 57%20) as the main channel for infectious disease information and to prefer using the internet for such information (62% vs 54%20). These findings have important implications for the use of telemedicine to fill gaps in health promotion and disease prevention. Wu et al30 found that secondary cases from household transmission of COVID-19 were common in Zhuhai, China, and one-third of these secondary cases were asymptomatic. Sufficient household preparation measures are needed to limit the spread of COVID-19.31

Telemedicine in Hong Kong had a ‘late start’ (in 1994); in 1998, Hjelm32 predicted that the telemedicine would be rapidly implemented in Hong Kong. However, in the December 2019 version of the Ethical Guidelines on Practice of Telemedicine by the Medical Council of Hong Kong, it was noted that telemedicine in Hong Kong has not fully developed.24 Despite the obvious convenience benefit and reduced risk of COVID-19 transmission, the guidelines remind practitioners that they remain fully responsible for legal and ethical obligations during telemedicine consultations.24 Furthermore, the guidelines mention that standards of care to protect patients are applicable during in-person and telemedicine consultations; practitioners should familiarise themselves with the World Medical Association Statement on the Ethics of Telemedicine.33

Training and patient assessment guidelines for healthcare practitioners are urgently needed, considering the unique circumstances surrounding the use of telemedicine, such as technology (eg, technical limitations of virtual consultations, including assessments), patient education and informed consent, cybersecurity, and other concerns.6 These guidelines would ensure that the same standards of telemedicine consultations can be implemented, as described by the Medical Council of Hong Kong.

The present study focused on 141 telemedicine users of a single private clinic providing deep throat saliva polymerase chain reaction tests for detection of severe acute respiratory syndrome coronavirus 2; thus, the study participants may not be representative of all telemedicine users in Hong Kong. Responder bias may have affected the results (the response rate was 75.4%), but it was not possible to compare participants with individuals who refused to participate. Furthermore, the recent experience of a telemedicine consultation may have biased participants’ responses in favour of telemedicine.

Concerning the comparison of COVID-19 risk perception and preparedness measures, methodological discrepancies between the online survey of telemedicine users and the telephone survey of the Hong Kong general public may have led to differences in responses, particularly with respect to including younger and more computer-literate individuals in the online survey. Although the present study was conducted from 6 April to 11 May 2020 (after a surge of COVID-19 cases in Hong Kong), the Hong Kong general public telephone survey used for comparison was conducted from 22 March to 1 April 2020 (during a surge in COVID-19 cases).20 The difference in data collection periods may have contributed to different perceptions of COVID-19 preparedness. Various physical distancing measures were implemented during the COVID-19 surge (from late March to early April), which may also have contributed to differences between the telephone survey and online survey cohorts.

Finally, because of sample size limitations and problems with representativeness, the findings of the study may be restricted to understanding views regarding telemedicine consultations among participants in the present study. However, factors such as young age, residence in private housing, and residence in the New Territories may have contributed to response bias; because no information was collected concerning occupation, education level, income, or ethnicity, we could not control for bias related to these factors.

In this study, telemedicine users in Hong Kong agreed that telemedicine consultations were appropriate during the COVID-19 pandemic. Participants agreed that telemedicine consultations could perform the functions of health protection, promotion, disease prevention, and diagnosis. The use of telemedicine for screening and patient education can be encouraged during the COVID-19 pandemic in Hong Kong.

Concept or design: KKC Hung, EYY Chan, JCY Wu.
Acquisition of data: KKC Hung, JCY Wu, CA Graham.
Analysis or interpretation of data: KKC Hung, EYY Chan, ESK Lo, Z Huang.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: KKC Hung.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

This research was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (Ref No.: SBRE-19-730). Patients were treated in accordance with the tenets of the Declaration of Helsinki and provided written informed consent for all treatments and procedures, as well as publication of their anonymised data.

1. Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med 2020;382:1679-81. Crossref

2. World Health Organization. Rapid assessment of service delivery for NCDs during the COVID-19 pandemic. Available from: https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic. Accessed 10 Aug 2020.

3. Peine A, Paffenholz P, Martin L, Dohmen S, Marx G, Loosen SH. Telemedicine in Germany during the COVID-19 pandemic: multi-professional national survey. J Med Internet Res 2020;22:e19745. Crossref

4. Ford D, Harvey JB, McElligott J, et al. Leveraging health system telehealth and informatics infrastructure to create a continuum of services for COVID-19 screening, testing, and treatment. J Am Med Inform Assoc 2020;27:1871-7. Crossref

5. Gong K, Xu Z, Cai Z, Chen Y, Wang Z. Internet hospitals help prevent and control the epidemic of COVID-19 in China: multicenter user profiling study. J Med Internet Res 2020;22:e18908. Crossref

6. Kung K, Wong HF, Chen JY. An exploratory qualitative study on patients’ views of medical e-consultation in a public primary care setting. Hong Kong Pract 2016;38:120-7.

7. Greenhalgh T, Koh GC, Car J. COVID-19: a remote assessment in primary care. BMJ 2020;368:m1182. Crossref

8. Fagherazzi G, Goetzinger C, Rashid MA, Aguayo GA, Huiart L. Digital health strategies to fight COVID-19 worldwide: challenges, recommendations, and a call for papers. J Med Internet Res 2020;22:e19284. Crossref

9. World Health Organization. A health telematics policy in support of WHO’s Health-for-all strategy for global health development: report of the WHO Group Consultation on Health Telematics, 11-16 December, Geneva, 1997. 1998. Available from: https://apps.who.int/iris/handle/10665/63857. Accessed 7 Sep 2023.

10. McLean S, Sheikh A, Cresswell K, et al. The impact of telehealthcare on the quality and safety of care: a systematic overview. PLoS One 2013;8:e71238. Crossref

11. Wootton R. Twenty years of telemedicine in chronic disease management—an evidence synthesis. J Telemed Telecare 2012;18:211-20. Crossref

12. Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2015;2015:CD002098. Crossref

13. Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform 2010;79:736-71. Crossref

14. Eze ND, Mateus C, Cravo Oliveira Hashiguchi T. Telemedicine in the OECD: an umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One 2020;15:e0237585. Crossref

15. Hung KK, Walline JH, Graham CA. COVID-19: emergency medicine perspectives from Hong Kong. Eur J Emerg Med 2020;27:163-4. Crossref

16. Hung KK, Walline JH, Chan EY, et al. Health service utilization in Hong Kong during the COVID-19 pandemic—a cross-sectional public survey. Int J Health Policy Manag 2022;11:508-13. Crossref

17. Auener S, Kroon D, Wackers E, Dulmen SV, Jeurissen P. COVID-19: a window of opportunity for positive healthcare reforms. Int J Health Policy Manag 2020;9:419-22. Crossref

18. Sheng OR, Hu PJ, Chau PY, et al. A survey of physicians’ acceptance of telemedicine. J Telemed Telecare 1998;4 Suppl 1:100-2. Crossref

19. CUHK Medical Clinic. COVID-19 Testing Service (Company/Groups). Available from: https://cuclinic.hk/programmes/covid-19-testing-service/covid-19-testing-testing-service-company-group. Accessed 30 Jul 2020.

20. Chan EY, Huang Z, Lo ES, Hung KK, Wong EL, Wong SY. Sociodemographic predictors of health risk perception, attitude and behavior practices associated with Health-Emergency Disaster Risk Management for biological hazards: the case of COVID-19 pandemic in Hong Kong, SAR China. Int J Environ Res Public Health 2020;17:3869. Crossref

21. Moore MA, Coffman M, Jetty A, Petterson S, Bazemore A. Only 15% of FPs report using telehealth; training and lack of reimbursement are top barriers. Am Fam Physician 2016;93:101.

22. Schwamm LH. Telehealth: seven strategies to successfully implement disruptive technology and transform health care. Health Aff (Millwood) 2014;33:200-6. Crossref

23. Pearl R. Kaiser Permanente Northern California: current experiences with internet, mobile, and video technologies. Health Aff (Millwood) 2014;33:251-7. Crossref

24. The Medical Council of Hong Kong. Guidelines for all registered medical practitioners. Available from: https://www.mchk.org.hk/files/newsletter-26th.pdf. Accessed 30 Jul 2020.

25. Barnett ML, Ray KN, Souza J, Mehrotra A. Trends in telemedicine use in a large commercially insured population, 2005-2017. JAMA 2018;320:2147-9. Crossref

26. Uscher-Pines L, Mehrotra A. Analysis of Teladoc use seems to indicate expanded access to care for patients without prior connection to a provider. Health Aff (Millwood) 2014;33:258-64. Crossref

27. Neufeld JD, Doarn CR. Telemedicine spending by Medicare: a snapshot from 2012. Telemed J E Health 2015;21:686-93. Crossref

28. Mehrotra, A. The convenience revolution for treatment of low-acuity conditions. JAMA 2013;310:35-6. Crossref

29. Courneya PT, Palattao KJ, Gallagher JM. HealthPartners’ online clinic for simple conditions delivers savings of $88 per episode and high patient approval. Health Aff (Millwood) 2013;32:385-92. Crossref

30. Wu J, Huang Y, Tu C, et al. Household transmission of SARS-CoV-2, Zhuhai, China, 2020. Clin Infect Dis 2020;71:2099-108. Crossref

31. Chan EY, Gobat N, Kim JH, et al. Informal home care providers: the forgotten health-care workers during the COVID-19 pandemic. Lancet 2020;395:1957-9. Crossref

32. Hjelm NM. Telemedicine: academic and professional aspects. Hong Kong Med J 1998;4:289-92.

33. World Medical Association. WMA Statement on the Ethics of Telemedicine. Available from: https://www.wma.net/policies-post/wma-statement-on-the-ethics-of-telemedicine/. Accessed 15 Apr 2021.