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COVID-19 Case Surge and Telemedicine Utilization in a Tertiary Hospital in Korea

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Introduction

Since December 2019, coronavirus disease 2019 (COVID-19) has quickly spread worldwide.1 In March 2020, the World Health Organization declared COVID-19 a pandemic.2 The global increase in COVID-19 cases suddenly and abruptly forced people to stay at home, maintain social distance, and reduce physical contact.3 Therefore, non-face-to-face services are emerging as a new normal in all sectors.4,5 Health systems are also shifting health care delivery to telemedicine.6

Telemedicine is the delivery of health care services using information or communication technology rather than through in-person doctor–patient meetings.7 Telemedicine allows the diagnosis and treatment of COVID-19 infections in outpatients from a distance.8 This enables continuity of care while simultaneously protecting patients from exposure to infection.9 The need for telemedicine has increased since the emergence of COVID-19.6 The world has come to understand and accept telemedicine.10 Several studies on telemedicine have been conducted in many countries.

In Korea, telemedicine faced stakeholder resistance in the past despite its great potential.11 However, as the Middle East respiratory syndrome spread rapidly in May 2015, the government allowed telephone-based telemedicine only in some hospitals. Nevertheless, this was for a limited time and did not last.12 After the spread of COVID-19, Korea temporarily allowed telephone-based telemedicine again from February 24, 2020.13,14

Telephone-based telemedicine is being implemented, at doctors’ discretion, in many hospitals across Korea to ensure safety.14,15 During the pandemic, many opportunities have arisen to evaluate the utility of telemedicine under a variety of circumstances. Moreover, there is a need to draw on the current experience to chart the future of telemedicine.16,17 We need to respond effectively to the prolonged COVID-19 pandemic and be better prepared to respond to future public health threats.18 To allow telemedicine, national policy should be established.19 Therefore, the status of telemedicine and the factors determining telemedicine choice should be analyzed and reported.

In existing studies, factors related to telemedicine use were sex, age, race, language, residence, and insurance type. Specifically, patients who were female, younger, and had commercial insurance were found to use telemedicine at higher rates.20–22 Conversely, telemedicine use among Asian patients who have a lower household income, live in distant locations, and use non-English languages was low.20–22 A Korean study reported that telemedicine could be used to manage mild patients and to screen patients.23 There have been studies on the reasons for counseling and the chief concerns regarding telemedicine.24,25 However, to our knowledge, no studies have analyzed the factors determining telemedicine choice after the countrywide permission of telemedicine use in Korea. Given this paucity of literature, this study aimed to analyze the factors related to telemedicine and report on telemedicine utilization at a tertiary hospital in Korea.

Materials and Methods

SETTINGS/SUBJECTS

The setting for this research was a large, Korean tertiary hospital in Seoul, which was selected for two main reasons. First, the hospital provides an ample sample because about 10,000 outpatients visit the hospital daily. Second, this hospital was well positioned to facilitate patient care during the COVID-19 pandemic because it had established infrastructure for telemedicine. These factors created a controlled environment suitable for telemedicine study.

Patients could choose their type of visit (telemedicine or in-person visit) from March 2020 because telemedicine was allowed in Korea at the end of February 2020. Therefore, a retrospective study was conducted using electronic medical record (EMR) data collected from outpatients between March 4 and September 4, 2020.

Only a small portion (1.0%) of the entire sample used telemedicine; therefore, we chose the comparison group by matching, adjusting for age and sex. Sex and age were the cause of bias when those who used telehealth were compared with those who did not to estimate characteristics.

VARIABLES AND MEASUREMENT

The use of telemedicine, the dependent variable, was categorized into telemedicine and in-person visits depending on patient choice. This study employed different patient characteristics, including sociodemographic and practice-related characteristics. For each patient included in the study, we used EMR data to identify sociodemographic (age, sex, region, and type of insurance) and practice-related (appointment channels, type of visit, departments, doctor’s position, major diagnosis, and the number of days since diagnosis) characteristics. The number of confirmed COVID-19 cases per day was obtained from Statistics Korea.

STATISTICAL ANALYSES

In this study, 1:5 propensity score matching was conducted using age and sex to match telemedicine and in-person visits. The Mantel–Haenszel test was performed for each covariate after matching the case and control. A chi-square test was used to examine the distribution of general characteristics according to telemedicine use. Multivariable logistic regression was performed to examine the factors associated with telemedicine use through odds ratios (ORs) with 95% confidence intervals. All statistical analyses were performed using SAS software (version 9.4; SAS Institute, Inc., Cary, NC).

INSTITUTIONAL REVIEW BOARD WAIVER STATEMENT

This study adhered to the Declaration of Helsinki and was reviewed by the Yonsei University Health System Institutional Review Board and was ruled exempt (IRB No. Y-2020-0213). Written informed consent from patients was waived as the study involved secondary data analysis using deidentified data.

Results

Figure 1 shows the frequency of telemedicine use following the COVID-19 outbreak. On January 20, 2020, a new COVID-19 case was discovered in Korea. Until mid-February, fewer than five new cases were reported, but on February 19, the number of new cases began to increase. The next day, the Korean government acknowledged the beginning of the COVID-19 infection in local communities. On February 24, 2020, telemedicine use was temporarily allowed to respond to COVID-19 patients.

Fig. 1.

Fig. 1. COVD-19 case surge and use of telemedicine in Korea. COVID-19, coronavirus disease 2019. Color images are available online.

During the first pandemic period (mid-February to March 2020), telemedicine was frequently administered in research hospitals. Telemedicine use decreased as the number of new confirmed cases decreased after observing social distancing (March 22 to May 5, 2020) and distancing in daily life (from May 6, 2020). Telemedicine use also increased during the second wave of the pandemic (mid-August 2020, Fig. 1).

Supplementary Table ST1 shows the general characteristics of telemedicine use. Of the 929,753 cases, 9,662 (1.0%) were allocated to the telemedicine visit group and 920,091 (99.0%) to the in-person visit group. After 1:5 fixed-ratio propensity score matching, 48,310 in-person visits and 9,662 telemedicine visits were retained for comparison.

Telemedicine use was high (21.4%) in other regions (provinces within Korea that fall outside Seoul and the Incheon, Gyeonggi, region) compared with Seoul, where the hospital was located. Telemedicine use was high in follow-up (17.1%) and return (17.2%) patients (Table 1).

Table 1. Comparison Between In-Person and Telemedicine Visits
VARIABLES TOTAL IN-PERSON VISIT TELEMEDICINE VISIT p
N %
Total 57,972 100.0 48,310 100.0 9,662 100.0  
Sex             1.0000
 Male 24,468 42.2 20,390 83.3 4,078 16.7  
 Female 33,504 57.8 27,920 83.3 5,584 16.7  
Age, years             1.0000
 ≤19 9,144 15.8 7,620 83.3 1,524 16.7  
 20–29 2,892 5.0 2,410 83.3 482 16.7  
 30–39 4,872 8.4 4,060 83.3 812 16.7  
 40–49 7,656 13.2 6,380 83.3 1,276 16.7  
 50–59 8,820 15.2 7,350 83.3 1,470 16.7  
 60–69 11,280 19.5 9,400 83.3 1,880 16.7  
 ≥70 13,308 23.0 11,090 83.3 2,218 16.7  
Region             <0.0001
 Seoul 23,040 39.7 20,206 87.7 2,834 12.3  
 Incheon, Gyeonggi, region 11,814 20.4 9,941 84.1 1,873 15.9  
 Other regions 23,118 39.9 18,163 78.6 4,955 21.4  
Type of insurance             0.0139
 National Health Insurance 55,038 94.9 45,818 83.2 9,220 16.8  
 Medical Aid 2,178 3.8 1,835 84.3 343 15.7  
 Industrial accident compensation, automobile insurance, international insurance, and private insurance 756 1.3 657 86.9 99 13.1  
Modes of appointment-making             <0.0001
 Walk-in/telephone 2,640 4.6 2,461 93.2 179 6.8  
 Follow-up 55,332 95.4 45,849 82.9 9,483 17.1  
Type of visita             <0.0001
 A 3,548 6.1 3,264 92.0 284 8.0  
 B 54,424 93.9 45,046 82.8 9,378 17.2  
Department             <0.0001
 Internal medicine 22,271 38.4 18,500 83.1 3,771 16.9  
 Surgery department 8,223 14.2 6,583 80.1 1,640 19.9  
 OBGYN 3,185 5.5 2,930 92.0 255 8.0  
 Pediatrics 7,466 12.9 5,872 78.6 1,594 21.4  
 Ophthalmology 3,436 5.9 3,272 95.2 164 4.8  
 Otolaryngology 1,799 3.1 1,384 76.9 415 23.1  
 Dermatology 1,959 3.4 1,855 94.7 104 5.3  
 Urology 1,922 3.3 1,639 85.3 283 14.7  
 Neuropsychiatry 1,952 3.4 1,705 87.3 247 12.7  
 Others 5,759 9.9 4,570 79.4 1,189 20.6  
Doctor’s position             0.3997
 Professional position 51,161 88.3 42,659 83.4 8,502 16.6  
 General position 6,811 11.7 5,651 83.0 1,160 17.0  
Major diagnosis             <0.0001
 A00-B99 1,303 2.2 1,156 88.7 147 11.3  
 C00-D48 4,879 8.4 4,066 83.3 813 16.7  
 D50-D89 2,638 4.6 2,168 82.2 470 17.8  
 E00-E90 6,970 12.0 5,385 77.3 1,585 22.7  
 F00-F99 3,115 5.4 2,464 79.1 651 20.9  
 G00-G99 3,147 5.4 2,302 73.1 845 26.9  
 H00-H59 4,002 6.9 3,664 91.6 338 8.4  
 I00-I99 5,274 9.1 4,194 79.5 1,080 20.5  
 J00-J99 2,611 4.5 2,108 80.7 503 19.3  
 K00-K93 8,145 14.0 7,092 87.1 1,053 12.9  
 L00-L99 1,889 3.3 1,697 89.8 192 10.2  
 M00-M99 3,378 5.8 2,807 83.1 571 16.9  
 N00-N99 2,693 4.6 2,315 86.0 378 14.0  
 O00-P96 515 0.9 491 95.3 24 4.7  
 Q00-Q99 952 1.6 819 86.0 133 14.0  
 R00-R99 3,006 5.2 2,483 82.6 523 17.4  
 S00-T98 593 1.0 551 92.9 42 7.1  
 U00-Z99 2,862 4.9 2,548 89.0 314 11.0  
Number of days from diagnosis, months             <0.0001
 3 15,244 26.3 13,773 90.4 1,471 9.6  
 3–6 4,624 8.0 4,021 87.0 603 13.0  
 6–12 6,567 11.3 5,490 83.6 1,077 16.4  
 12–36 13,842 23.9 11,186 80.8 2,656 19.2  
 ≥36 17,695 30.5 13,840 78.2 3,855 21.8  
Number of new COVID-19 cases in the preceding week             <0.0001
 <101 12,635 21.8 12,001 95.0 634 5.0  
 101–300 18,127 31.3 16,044 88.5 2,083 11.5  
 301–500 14,972 25.8 12,989 86.8 1,983 13.2  
 ≥501 12,238 21.1 7,276 59.5 4,962 40.5  

Telemedicine was used most in the otolaryngology department (23.1%), followed by pediatrics (21.4%), surgery (19.9%), and others (all other departments; 20.6%) (Table 1). Telemedicine use increased as the number of days from diagnosis increased. Telemedicine was used in 21.8% of cases when over 36 months had passed since the day of diagnosis. Telemedicine was used more often as the number of new COVID-19 cases for the preceding week increased. Over 501 new COVID-19 cases in the preceding week led to telemedicine use by 40.5% of patients.

Table 2 shows the results of the multivariable logistic regression analysis of factors associated with telemedicine use during the COVID-19 pandemic. When there was a high number of new COVID-19 cases in the preceding week, the number of patients who used telemedicine significantly increased (101–300 new cases OR: 3.00; 301–500 new cases OR: 5.82; and ≥501 new cases OR: 42.18). Female patients were more likely to use telemedicine than male patients (OR: 2.08). The rates of telemedicine use were higher among patients who were aged older than 20 years than among those who are 19 years old or younger (≤19) (20–29 years OR: 3.06; 30–39 years OR: 4.64; 40–49 years OR: 4.33; 50–59 years OR: 2.25; 60–69 years OR: 1.51; and ≥70 years OR: 3.69). Patients living in the Incheon, Gyeonggi, region (OR: 1.30) and other regions (OR: 4.33) were more likely to use telemedicine than patients living in Seoul. Medical Aid (MA) patients (OR: 0.83) were less likely to use telemedicine than National Health Insurance (NHI) patients. Follow-up patients (OR: 1.91) were more likely to use telemedicine than walk-in patients and patients who were booked by telephone. Telemedicine use increased with an increasing number of days from diagnosis (3–6 months OR: 1.21; 6–12 months OR: 1.56; 12–36 months OR: 1.98; and ≥36 months OR: 2.49).

Table 2. Multivariable Logistic Regression of Factors Associated with Telemedicine During the COVID-19 Pandemica
VARIABLES OR 95% CI p
Sex
 Male Ref.      
 Female 2.08 1.96 2.21 <0.0001
Age, years
 ≤19 Ref.      
 20–29 3.06 2.60 3.61 <0.0001
 30–39 4.64 3.95 5.45 <0.0001
 40–49 4.33 3.71 5.05 <0.0001
 50–59 2.25 1.93 2.63 <0.0001
 60–69 1.51 1.30 1.75 <0.0001
 ≥70 3.69 3.17 4.29 <0.0001
Region
 Seoul Ref.      
 Incheon, Gyeonggi, region 1.30 1.21 1.39 <0.0001
 Other regions 4.33 4.07 4.62 <0.0001
Type of insurance
 National Health Insurance Ref.      
 Medical Aid 0.83 0.72 0.95 0.0078
 Industrial accident compensation insurance, automobile insurance, international insurance, and private insurance 1.14 0.90 1.45 0.2904
Modes of appointment-making
 Walk-in/telephone Ref.      
 Follow-up 1.91 1.61 2.27 <0.0001
Number of days from diagnosis, months
 3 Ref.      
 3–6 1.21 1.08 1.36 0.0009
 6–12 1.56 1.42 1.72 <0.0001
 12–36 1.98 1.83 2.14 <0.0001
 ≥36 2.49 2.32 2.68 <0.0001
Number of new COVID-19 cases in the preceding week
 <101 Ref.      
 101–300 3.00 2.71 3.32 <0.0001
 301–500 5.82 5.20 6.51 <0.0001
 ≥501 42.18 37.97 46.85 <0.0001

Discussion

The COVID-19 pandemic has brought about rapid and widespread changes to the health care system.26 Telemedicine has been adopted to prevent contact with the infectious virus while maintaining continuity of patient care.27,28 The objective of this study was to offer a better understanding of the utilization of telemedicine in complex and novel settings, as were the circumstances of the early COVID-19 pandemic.16

The results of this study contribute to the emerging literature on telemedicine in Korea. First, we found that the use of telemedicine increased with an increase in the number of confirmed COVID-19 cases. This finding is consistent with previous telemedicine effectiveness studies, which reported that the use of telephone-based telemedicine increased, while in-person visits decreased, as COVID-19 spread.29,30 Despite the nationwide implementation of telemedicine in Korea being unprecedented, telemedicine use has increased during the COVID-19 pandemic. This indicates that people have a positive perception of and a heightened need for telemedicine to maintain continuity of care and reduce the risk of infection.31 In the face of COVID-19, South Korea has not implemented a nationwide lockdown, unlike other countries.32 In addition, no hospital has been closed due to COVID-19. Despite the lack of nationwide lockdown, the social distancing campaign implemented by the Korean government was more robust.32 This study identified an increase in telemedicine use during the social distancing campaign in Korea. Telemedicine is a timely and useful means to significantly mitigate the spread of COVID-19 and prevent transmission to medical staff.33 Thus, telemedicine is expected to play a valuable role in protecting public health workers during the COVID-19 pandemic and future outbreaks of other infectious diseases.33 It also shows the need to consider long-term plans for telemedicine. The plans should be sustainable during and after the COVID-19 pandemic.

Second, telemedicine use was higher in regions other than Seoul and the Incheon, Gyeonggi, region located close to the hospital. These findings suggest that telemedicine has the advantage of reducing the time and cost incurred by in-person visits; therefore, people may prefer telemedicine in the post-COVID-19 era. This is consistent with prior studies, which found that the distance from the hospital to house is relevant in choosing telemedicine.22 The reason is likely that telemedicine allows patients to save indirect costs, considering the costs of occupational leave and early leave, transportation (bus or train fares, etc.), meals, and fuel.34 As such, when telemedicine is properly utilized, it can be an effective alternative for patients.34 These results indicate that telemedicine is useful for patients living in distant locations and the focus should be on these patients when determining the scope of telemedicine.

Third, telemedicine use increased as the number of days from diagnosis increased. As the disease progresses, treatment is conducted for periodic checkups and repeated medications. Thus, it is assumed that the reason for requiring in-person visits decreases from the acute to the chronic disease phase. Previous studies have reported that telemedicine is useful for treating chronic diseases.35,36 The results of this study showed that the number of days from diagnosis plays a direct and crucial role in determining telemedicine use. These results suggest that patients in the subacute and chronic phases can be adopted when considering the scope of telemedicine. Furthermore, the period of progression from acute to chronic disease varied according to the characteristics of the disease. Further research should consider the disease and the number of days from diagnosis.

Fourth, age groups other than patients aged ˂19 years were more likely to use telemedicine. Notably, telemedicine use was high among patients between the ages of 30 and 49. Patients of this age group are relatively open to telemedicine treatment conducted through smartphones and the internet.31 In addition, most patients of this age group have a job, meaning that they utilized telemedicine more often for convenience and to reduce the time and cost required for hospital visits.31 On the contrary, this finding can be interpreted as stemming from the fact that the proportion of critically ill pediatric patients is high because the hospital of this study is a tertiary hospital, and that critically ill pediatric patients are more likely to prefer face-to-face treatment over telemedicine because their guardian such as parents or grandparents accompany them for the treatment.

Finally, we observed that patients with MA coverage had lower rates of telemedicine use than those with general health insurance. This result is consistent with previous studies showing that patients on MA use telemedicine less often. In the United States, the reasons for less telemedicine use are the lack of digital access and differences in telemedicine reimbursement by states.37,38 In Korea, the reasons for this are different. About 97% of the population is covered by the Korean NHI system, the universal medical insurance in Korea.39 The NHI system started providing coverage for industrial workers of large corporations in 197740; also implemented in 1977 was the MA program, which supports the underprivileged population in need of medical assistance as part of the social welfare program by the National Basic Livelihood Security System. The MA program is analogous to the Medicaid program in the United States. The NHI system requires the insured and dependents who receive health care services to pay copayments as a part of total health care expenses.41 Generally, a 20% coinsurance rate is applied to the charges for inpatient services, while 30–60% of the coinsurance rate is charged for outpatient services depending on the level of health care institutions.41 MA program Type I beneficiaries are not required to provide copayments for all medical services they use, while Type II beneficiaries have minimum copayment rates of up to 15%.42,43 Patients with NHI pay less for telemedicine than for in-person visits. On the contrary, there is no difference in cost between telemedicine and in-person visits for patients in the MA program.44 Thus, for patients in the MA program, telemedicine is not cost-effective. Moreover, these patients are presumed to prefer in-person visits because they have vulnerable characteristics, such as older age and a low level of education.

This study has several limitations. First, our study period was limited to 6 months, from March 4, 2020, when data collection on telemedicine use began, to September 4, 2020. However, the COVID-19 pandemic is prolonged, and the trend of infection continues to change. Therefore, more months of data are necessary to obtain significant findings. Second, this study is based on a single-center experience and thus may not be widely generalizable. The medical conditions and characteristics of patients may differ depending on the role and size of the hospital. Thus, further trials in various hospitals are needed for the results of this study to be generalizable. Despite these limitations, the significance of this study is that it is the first study to assess telephone-based telemedicine after its nationwide implementation in Korea. Moreover, our study results show the current status of telemedicine use during the COVID-19 pandemic.

Still, some unresolved questions and issues remain to be explored, such as how the perceptions of telemedicine change and how to get more people to adopt telemedicine. Further studies are required to evaluate the clinical outcomes and satisfaction with telemedicine adoption and utilization. Finally, to continue and expand telemedicine, we should determine the target patients and establish a national policy.45 By establishing a systematic policy, as well as ongoing acceptability by patients and health care providers, telemedicine may continue to serve as an important modality for delivering care during and after the pandemic.

Conclusions

In the overall analysis, we found that with the surge in COVID-19 cases, there was significant increase in telemedicine use. This suggests that telemedicine can be effective in delivering health services during an outbreak. Furthermore, telemedicine utilization was also related to distant locations, increased days from diagnosis, and MA coverage. The results of this study are expected to facilitate the use of telemedicine.

Authors’ Contributions

H.S.K. and T.H.K. were involved in concept and design. B.K. was involved in statistical analysis. H.S.K., B.K., S.G.L., and T.H.K. were involved in drafting of the manuscript. S.G.L. and T.H.K. were involved in supervision.

Authorship Confirmation Statement

All coauthors have reviewed and approved the manuscript before submission.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Table S1

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