Abstract
Telemedicine aims to slow the spread of infection, enhance the quality and cost of healthcare, and increase patient engagement and satisfaction. Recently, the Japanese government has promoted the use of telemedicine. Despite the efforts of the government, the service is not in widespread use in Japan, even in the era of the COVID-19 pandemic. The present study aims to assess the awareness of telemedicine among Japanese older adults and learn about their experiences with the service. Furthermore, it aims to understand the patients’ needs and perspectives for creating a user-friendly telemedicine service. Therefore, one hundred and ten outpatients with chronic diseases were contacted during the COVID-19 pandemic, and data were collected from them using face-to-face questionnaires. Group 1 and group 2 separately include 55 patients aged 40 to 64 years, and 65 years and above, respectively. Statistical analyses were conducted using Microsoft Excel 2019, AutoSum feature “Ʃ,” with statistical significance set at P < .05 by t-test, to compare the means of the 2 groups of participants. The survey results revealed that one patient in each group (2 out of 110 people) had experience using the remote consultation service. The acceptance of telemedicine concept by age and gender was found to be greater among middle-aged adults (2.9, SD 0.7) and male patients (2.9, SD 0.6) than among older adults (2.5, SD 0.8) and female patients (2.5, SD 0.9), and the difference in each aspect was significant (P = .012, 0.024), respectively. Middle-aged adults (2.8, SD 0.6) were also found to be more willing to use the service in the future than older adults (2.5, SD 0.7), and the difference was significant (P = .037). On the other hand, the limited use of telemedicine among the study participants was due to the following main factors; limited knowledge of the service, usability challenges of technology, and cultural factors. Regarding the development of telemedicine, key recommendations were made for creating a user-friendly telemedicine that meets the needs of as many as possible of patients. In conclusion, there are challenges that affect the growth of telemedicine in Japan. Therefore, learning about the patients’ perspectives and needs play an important role in increasing telemedicine utilization. The outcomes of the present study will be useful to researchers, designers, engineers, and all those interested in this field of research.
Highlights
● Age and gender showed significant differences in acceptance and willingness to use telemedicine.
● Developing a user-friendly telemedicine system requires providing patients with clear and effective usage guidelines, as well as simplifying the service technology.
● Future studies are recommended to identify the unique healthcare needs of women and older patients that go beyond traditional home diagnosis to be addressed through the telemedicine services.
Introduction
In Japan, telemedicine was officially approved as a medical option in 1997, but for a long time its use was limited to special situations such as the remote island setting. 1 Lately, telemedicine has become a significant segment of the global healthcare industry. The COVID-19 pandemic was a major driver for telemedicine’s uptake due to its many benefits, which include reduced patient/provider exposure to infectious diseases, greater patient access to healthcare services, and increased flexibility of hospital resource utilization. 2 Online consultations are being used as a solution for rural healthcare. Furthermore, it is used for specialized outpatient services, such as for headaches or cancer consultations (second opinions), and collaboration with industrial physicians and school doctors is also taking place. 3 Telemedicine reduces patient travel time and costs, empowers patients, and engages them in self-care. 4
Recognizing its value, the Japanese government has promoted the use of telemedicine1,2 by easing telemedicine regulations in the Japanese national health insurance system both during and after the pandemic.2,5 Despite the efforts of the government, telemedicine is not in widespread use in Japan, even in the era of the COVID-19 pandemic. 1 This was obvious, as at the end of October 2020, only 16 587 of the 110 916 healthcare institutions in Japan were registered as having systems for providing remote consultations over telephone or the internet. 6 This is only about 15% of healthcare institutions.6 -8
There are different barriers preventing the widespread use of online healthcare, including patients’ need to switch to face-to-face medical care for mandatory tests and procedures, and inadequate awareness and education on online medical care. 9 Another important barrier that keeps Japan lags far behind other countries in the use of digital health is the aging patients and healthcare professionals, and the need for greater efficiency is high. 10 In this context, a previous study indicated that there is a large generational imbalance among users of online medical treatment. According to a Health, Labor and Welfare Ministry survey on the number of patients receiving such treatment during the pandemic, 70% were aged 40 or younger, and older adult people accounted for only a small percentage. 11
Recently, there are important factors that are likely to pressure the Japanese healthcare system to increase the telemedicine utilization rate. 2 First, Japan is now the world’s fastest aging country, and the Government of Japan (GOJ) has actively started the process of promoting the home medical care industry for the country’s senior citizens. 12 Approximately one-third of Japan’s population is over the age of 65,2,13,14 and this age category is expected to grow-increasing healthcare demand. 2 Second factor, many members of this elderly population live in rural areas, decreasing accessibility to medical facilities. Third, Japan faces a simultaneous shortage of healthcare professionals. 2
In light of the above, previous studies indicated that the expansion of telemedicine is urgently required to adapt to an aging society; therefore, research that enhances the quality of telemedicine, and patient satisfaction is needed.2,4 The present study aims to assess the awareness of telemedicine among Japanese older adults and learn about their experiences with the service. Furthermore, it aims to understand the patients’ perspectives and needs for creating a user-friendly telemedicine service.
Methods
This is a quantitative user research, using a face-to-face (F-to-F) questionnaire (a personal meeting was held between a medical staff and a patient to answer the questionnaire). During the COVID-19 pandemic (the Japanese government declared a state of emergency due to COVID-19 pandemic in April 2020 and ended in May 2023),15,16 personal interviews were conducted with 110 outpatients (55 Female and 55 male) with chronic diseases between February 2022 and April 2023.
The interviews were conducted in one of the largest and advanced hospitals in Japan located in Fukuoka city, which receives 2900 outpatients per day on average. During the first wave of COVID-19, the hospital offered remote consultations via telephone “audio-telemedicine visit, the most common telemedicine modality in Japan” for patients with chronic diseases. Participants were selected based on 4 criteria: age (from 40 to 64 years, and from 65 years and over), suffering from chronic diseases, suitability of the patient’s condition for a telemedicine visit from the physician’s point of view (meaning that the patient whose health condition is stable and does not require an in-person follow-up appointment), and consent to participate in this study. Patients who did not meet the above inclusion criteria were excluded from the study.
Regarding participant categories, there are factors that impact telemedicine usage, such as age and employment status.1,17 Therefore, before learning about patients’ experiences and identifying their unique needs, our participants were divided into two groups based on previously published articles,18,19 considering the above-mentioned factors. In the context of employment, the first group includes middle-aged adults, aged 40 to 64 years old. The second group of participants includes older adults who have reached retirement age 65 years and over.
Participation in this study was voluntary, without any financial incentive or coercion. The authors did not provide any compensation to older adults for participating. There was no penalty for not participating. Participants can discontinue their participation and withdraw from the study at any time without penalty. A few people declined to participate in this study. All participants were provided with an explanation of telemedicine and all information about the study, including the reasons for undertaking the survey.
The study questionnaire was created based on a review of previously published research articles,20 -22 and then was piloted on a patient sample (n = 10) representing the study target group to verify how individuals understood and responded to proposed survey design. Pilot study patients were selected by the physicians participating in this study based on the 4 criteria mentioned above, and their participation was voluntary, without any financial incentive or coercion. Based on the responses of these 10 people, the authors modified the questions for clarity.
Probing questions were used to assess the awareness of telemedicine, and to understand the patients’ needs for developing telemedicine. The questionnaire sheets were delivered to 7 doctors (departments of internal medicine, Otolaryngology, Orthopedic, and Dermatology) interested in telemedicine by hand to conduct F-to-F interviews with their patients. The average duration of the interview with each participant was about 30 min.
The questionnaire (15 close-ended questions) consisted of 3 parts. Part A included the characteristics of patients (6 questions), part B was about the clinic consultation versus telemedicine (5 questions), and part C investigated the use of telemedicine and patient’s needs (4 questions). The assessment of health status was measured by a Likert type scale, 1 = quite healthy; 2 = slightly healthy; 3 = not so healthy; 4 = not healthy. Similarly, satisfaction and acceptance were measured by a scale; 1= to a great extent; 2 = somewhat; 3 = very little; 4 = not healthy. Willingness to use telemedicine was measured by a scale; 1 = yes; 2 = probably yes; 3 = probably no; 4 = no.
Statistical Analysis
STATA var 18.0 (StataCorp. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC.) was used to confirm the normal distribution by Shapiro-Wilk test at first. The probability for hypothesis normal distribution of the data was .47011 for the score data of receptive telemedicine, and .34517 for the score data of willingness for telemedicine by Shapiro-Wilk test. So, the data were confirmed the normal distribution statistically.
Next, we used Microsoft Excel 2019, AutoSum feature “Ʃ,” with statistical significance set at P < .05 by t-test, to compare the means of the 2 groups of participants.
Results
A total of 110 patients of which female (55) and male (55) completed the questionnaire. The following are the main results of the survey.
The Characteristic of Patients
Two groups of patients, totaling 110 individuals, participated in this study (Table 1). Group 1 (G1-middle-aged adults) includes 55 patients with ages ranging from 40 to 64 years (33 females and 22 males), and group 2 (G2- older adults) includes 55 patients with ages ranging from 65 years and above (22 females and 33 males). Patients in both groups had chronic illness, including high blood pressure, diabetes, gastrointestinal diseases, cardiovascular diseases, hyperuricemia, dyslipidemia, osteoarthritis/spine disorder, urologic diseases, and others.
Characteristics of Study Participants (n=110).
The results of the survey revealed that more than half of patients (64% of G1 and 55% of G2) are in a slightly good health, stable condition, and with no motor impairment. About 74% of G1 and 80% of G2 chose “clinical consultation” as their main reason for going to the hospital. Regarding monthly hospital visits, it was found that in both groups, 44% (24/55) of female patients and 36% (20/55) of male patients go to the hospital once a month for check-ups, and a blood test was chosen as a routine health check-up performed for 49% of G1 and 61% of G2 in the hospital. On the other hand, patients were asked about their experiences with telemedicine at this hospital and/or other hospitals. Patients’ responses revealed that during the COVID-19 pandemic, one patient in each group (2 out of 110 patients) had experienced audio call consultation once or twice. Since the first wave of COVID-19, patients have used in-person visits, but have limited their visits to avoid infections in the hospital.
Clinic Consultation Versus Telemedicine
In terms of patient satisfaction with in-person visit, the present study found that more than half of patients (58%) in G2 and 23 (43%) patients in G2 were very satisfied with in-person visit (Table 2). Regarding patient satisfaction with telemedicine, patients in G1 and G2 did not answer a question because almost all of them had no actual experience in using the service (Table 3). On the other hand, patients were asked about the problem/s that they face with their F-to-F visits, we found that more than half of patients (n = 33, 60%) in G2 had no problem with their F-to-F visits, while 14 (25%) patients in this group along with 22 (40%) patients in G1 answered that long waiting times to see the doctor is the main problem of F-to-F visits (Table 2). Regarding the main problem/s of the telemedicine service, this study results showed that more than half of patients (n = 29, 53%) in G1 and (n = 31, 56%) in G2 had limited information about the service. Furthermore, 28 (51%) patients in G2 compared to only 10 (18%) patients in G1 indicated that they were unwilling to use telemedicine due to their lack of digital skills (Table 3).
Patient Satisfaction and Problems with Face-to-Face Visit.
Patient Satisfaction and Problems with Telemedicine.
Use of Telemedicine and Patients’ Needs
In this study, patients in G1 and G2 were asked about their interest and acceptance of the idea of meeting a doctor via technology. The results showed that more than half of the patients in each group were somewhat receptive to the concept of telemedicine: the acceptance by age was about 51% of middle-aged and 53% of older adults, and acceptance by gender was about 58% of males and 45% of females (Table 4).
Acceptance of Telemedicine Concept by Age and Gender.
Note. P < .05, probability by T test.
SD = standard deviation.
Statistical analysis showed that the mean levels of telemedicine acceptance by age and gender were higher among (2.9, SD 0.7) middle-aged adults and (2.9, SD 0.6) male patients than among (2.5, SD 0.8) older adults and (2.5, SD 0.9) female patients, and the differences were significant (P = .012, 0.024), respectively (Table 4).
Regarding patients’ willingness to use telemedicine (Table 5), the study found that more than half of the patients (63% of G1 and 56% of G2) will probably use the service in the future.
Patients’ Willingness to Use Telemedicine Service in the Future.
Note. P < .05, probability by T test.
SD = standard deviation.
Statistical analysis showed that the mean level of willingness to use telemedicine was higher in (2.8, SD 0.6) G1 than in (2.5, SD 0.7) G2, and the difference was significant (P = .037).
Regarding the question about the benefits of telemedicine (Table 6), patients who were not willing to use the service in the future (2 patients in G1, and 6 patients in G2) declined to answer this question. The responses of the remaining patients in both groups (n = 53 in G1, and n = 49 in G2) revealed that more than half of the patients (57%) in G1 believed in the importance of telemedicine in saving time, while 21 (43%) patients in G2 did not answer the question despite their willingness to use the service. Furthermore, 18 (34%) patients in G1 and 16 (33%) patients in G2 pointed out that telemedicine could be a good way to avoid infectious diseases.
Patients’ Needs/Insights into the Use of Telemedicine.
With respect to the most essential tip to improve telemedicine in the future, more than half of patients (60% in G1, and 50% in G2) indicated the importance of creating a user-friendly telemedicine “easy to understand and use.”
Discussions
The rapid advancement of digital technology has transformed healthcare delivery, with telemedicine emerging as a vital tool for improving accessibility, efficiency, and patient-centered care. 23 Despite its values, all participants, except 2 patients were not telemedicine users, even in the COVID-19 pandemic. In addition, more than half of patients (63% in G1 and 56% in G2) indicated that there are possibilities of using the service in the future.
It can be said that the limited use of telemedicine among the study participants is related to the following 3 main issues; limited knowledge of the service, usability challenges of technology, and cultural factors.
Issue 1: Limited Knowledge of Telemedicine
The current study revealed that 29 (53%) patients in G1 and 31 (56%) patients in G2 had limited knowledge of the service. This was obvious, as many patients (n = 21, 43%) in G2 did not answer the question regarding the benefits of telemedicine. Attitudes toward online medical care may change after individuals gain firsthand experience with it. 9 Thus, educating patients about the service and how to use it is a key to increase the spread of telemedicine.
Recently, various studies have discussed challenges of doctor-to-doctor telemedicine, such as technical challenges and solutions, 24 as well as the need for developing a sort of guidelines for the implementation of telemedicine, 25 while there has been a lack of studies that have addressed patient education and guidance for the telemedicine visit (doctor-to-patient telemedicine), including the procedures for setting up and conducting online visits, as well as when the use of telemedicine is appropriate. 26
Regarding the importance of telemedicine use guidelines for patients, a global study stated that to maximize the efficiency, utility and value of a telemedicine visit, it is crucial for both physician and patient to be properly educated and prepared for such visits. 27 Previous surveys have also shown high patient satisfaction with the telemedicine visits, however patients frequently noted overall setup, technological barriers, and appointment expectations as points for future improvement. 27 Creating handouts on best practices for telemedicine and other educational resources can ease patients’ anxiety and enhance their experience with telemedicine visits. 28
Based on all mentioned above, this study recommends developing a set of clear tips for patients to increase their awareness of telemedicine and provide them with complete information about the advantages and disadvantages of the service, the conditions that can be treated through telemedicine, what to expect, how to easily prepare for online appointments, and the legal aspects associated with the service delivery.
Issue 2: Usability Challenges of Technology
In recent years, the Japanese government has promoted telemedicine as part of a national growth strategy for information and communication technology. 29 At present, the technological advancements of telemedicine in Japan have evolved exponentially with the introduction of cutting-edge technologies such as Artificial Intelligence (AI), Internet of Things (IoT), and robotics. 30 AI will intervene in the management of telemedicine, both in its operational management and in the management of the disease itself. 4 Basically, these technologies are improving the quality of care, and enable greater access to healthcare, while also helping to lower healthcare costs. 30 But technology is useless if people cannot use it.
According to research about Internet usage in Japan by the Ministry of Internal Affairs and communications, less than half of the Japanese population aged 70 and over used the Internet in 2017, compared to over 90% for people aged 13 to 59 years old. 13 Older adults are likely to be less tech-savvy (low familiarity with ICT) than other segments of the population.31,32 A previous survey conducted from April to June 2020 by the Ministry of Health, Labor and Welfare revealed that the percentage of the elderly aged used telemedicine was only 5.5%. Usability of telemedicine applications is the main influencing factor for user acceptance of the service. 8 In this context, it was reported that a decline in technology use as age increases.17,33,34 Furthermore, a recent study indicated that online healthcare usage is positively associated with employment status but negatively associated with age. 17 Similar results are presented in the current study that more than half of older patients (51%) in G2 had a lack of technological knowledge. Furthermore, the patients of G2 were found to be less willing to use telemedicine than the patients of G1 (2.5, SD 0.7 vs 2.8, SD 0.6) and the difference was significant (P = .037). These results are consistent with previous studies reported that younger individuals were generally more likely to increase telemedicine use than older individuals during the COVID-19 pandemic.1,35
In light of the above findings, it can be said that age is one of the factors that play a significant role in the service utilization, and making older patients comfortable with telemedicine is somewhat a challenge. Therefore, besides working to improve digital skills of the seniors, 13 it is important to make the use of telemedicine less difficult for patients, thus maximizing the efficiency and value of the service.
To create a user-friendly telemedicine service that more than half of participants (60% in G1 and 50% in G2) needed, our study recommends facilitating and simplifying telemedicine technologies, including devices, tools and apps, as well as avoiding long processes. To achieve this, a recent study highlighted that developers should consider the possibility of involving end users in the development process of digital health devices. 36 The involvement of patients in the early stages of technology development can enable the design of more user-centered technologies, and contribute to the early identification of potential issues, thus avoiding the addition of features that patients do not need. 36
Issue 3: Cultural Factors/Preferences
A previous study stated that there is a strong cultural bias toward face-to-face (F-to-F) consultation in Japan, but the servicing rural and remote areas by doctors is increasingly difficult so there is an urgent need to increase the uptake of telemedicine. 37 The current study presented similar findings that the majority of patients in both groups satisfied with in-person visit, especially among older patients (58% of G2 and 42% of G1), and about 60% of patients in G2 had no problem with F-to-F visit. It was also found that the percentage of patients who preferred F-to-F communication to phone communication was higher in (51%) G2 than in (22%) G1. Furthermore, statistical analysis showed that older patients were less receptive to the idea of meeting doctors via technology than mid-aged patients (2.5, SD 0.8 vs 2.9, SD 0.7), and the difference was significant (P = .012).
From the above, it can be said that the acceptance of in-person visit among older patients was higher than among younger patients due to various reasons, including that younger individuals are less likely to have disabilities and sensory barriers (like sensory changes of older people such as hearing loss) that could be hurdles to telemedicine use. 35 Moreover, a benefit beyond in-person consultation is that older patients are more likely to enjoy the social aspect of a doctor’s face-to-face appointment. 8 In Japan, visiting a physician’s office might be a strategy to handle loneliness for a large proportion of older adults. 8
On the other hand, one of the interesting findings in the present study is about the gender discrepancy in the use of telemedicine. In contrast to previous studies,29,38 statistical analyses of this study showed that the idea of meeting a doctor via technology was more attractive and receptive to male patients (2.9, SD 0.6) than female patients (2.5, SD 0.9), and the difference was significant (P = .024). Men may be more receptive to telemedicine than women because they are more interested in science, engineering majors (STEM fields) than women. 39 Although male patients showed their interest and receptivity to the service, the results of various studies consistent with this study, indicated that men are less likely to seek healthcare services than women.40 -43 Therefore, the present study believes that attracting more female patients to telemedicine can play an effective role in spreading the service, especially since women constitute the majority in society. 44
Considering this, attracting more patients to the service requires understanding their specific needs, priorities, concerns, and limitations. Future studies are needed to determine requirements/concerns of particular groups of people, including women and older patients, that can be addressed through telemedicine services rather than in-person visits. This will expand the scope of telemedicine services beyond traditional home diagnosis and monitoring activities to include more medical care forms, such as remote medicine management for older adults, 45 and digital education for mothers of children with special needs “education via telemedicine” to increase their knowledge level and reduce burden of care. 46
Overall, it can be said that the real success of telemedicine begins with understanding the users’ problems and needs. Involving patients in the service design process is useful for improving service performance, and thus increasing patient satisfaction and outcomes.
Limitations and Strengths
As with any research there are some limitations to the study. First, the current study focused on Fukuoka city, and only on the top public hospitals, particularly those offering remote consultation. Future research should expand the scope of our research and examine multiple sites in Japan as a comparative study. Second, the calculation of the sample size selected was not performed for this study. Third, the current study was conducted at the height of the COVID-19 pandemic, with a decline in hospital visits by older patients during that period. So, the interviews were conducted with a relatively small number of Japanese patients and the results cannot be generalized beyond the participants of this study. The participants expressed their own needs and perspectives to develop telemedicine, and these may not express the needs and views of the majority of Japanese people. Fourth, due to limited knowledge about telemedicine among older participants, many did not respond to the survey question about its benefits. This is a limitation since the sample sizes were not that big to begin with.
There were also, however, several strengths of the study that make it novel research. This is the first study in Japan to assess awareness of telemedicine among older adults, highlighting age and gender discrepancies in telemedicine acceptance, as well as identifying a group of patients with low willingness to use the service due to various barriers. Furthermore, the recommendations made in this study will be useful to make telemedicine more usable for many patients. On the other hand, F-to-F interviews were conducted with patients rather than online survey to avoid participants misunderstanding the questions, and to gather detailed insights into patients’ perspectives and needs.
Conclusions
Telemedicine plays a great role in improving access to healthcare services and saving costs. However, it is still not widely used in Japan. Therefore, it is increasingly important to identify the factors that limit the use of telemedicine from the older patients’ views, and to provide solutions that will facilitate its use. In this study, gender and age showed statistically significant differences in the telemedicine acceptance, and willingness to use it. Furthermore, there are 3 main factors behind the low rates of telemedicine use among the study participants: limited knowledge of the service, usability challenges of technology, and cultural factors. Thus, improving the satisfaction of existing users and attracting new patients would be through creating a user-friendly telemedicine system, which requires developing clear guidelines for patients to increase their awareness of the service, as well as educating them on how to prepare for and conduct the online visits easily. It is also important to simplify patients’ experiences with video consultations by streamlining telemedicine technologies including devices, tools and apps, as well as avoiding long processes.
Supplemental Material
sj-docx-1-inq-10.1177_00469580251371879 – Supplemental material for Considerations for Creating a User-Friendly Telemedicine Service in Japan
Supplemental material, sj-docx-1-inq-10.1177_00469580251371879 for Considerations for Creating a User-Friendly Telemedicine Service in Japan by Nermin Elokla, Tomohiko Moriyama, Daisuke Murakami, Naoki Nakashima and Mariko Nishikitani in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Acknowledgements
The authors would like to thank Dr. Nakahara Makiko, and all doctors at the Kyushu University Hospital participating in this study for their support.
Ethical Considerations
All study procedures were approved by form of ethics board. This study received ethical approval (including informed consent) from the Kyushu University Hospital, permission numbers: 2020-226 (Date 31.7.2020), 2021-462 (Date 31.3.2024) and 24284 (Date 31.3.2027).
Consent to Participate
We gained written informed consent for this study from all participants.
Author Contributions
NE and NN contributed to conception and design of the study. NE, TM, DM and NN, all collected data. NE contributed to the data analysis, and TM assisted in the data analysis. NE performed the statistical analysis, and MN assisted in the statistical analysis. NE, NN and TM were involved in gaining ethical approval. NE contributed to writing the original manuscript, and TM, DM, NN, and MN contributed to the revision of the manuscript. All authors read and approved the final article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by JSPS KAKENHI (Grant-in-Aid for Scientific Research C) Grant Number 24K15617.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data of this article is not available: the participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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