Bridging the Digital Divide: Creating a Personalized Telehealth Experience

Technology advances over the past decades have taken telehealth from a novel concept to a widespread reality. In the years leading up to 2020, the adoption of telehealth was growing steadily — but not staggeringly — in healthcare practices and hospitals.¹

Beginning in March 2020, the COVID-19 pandemic magnified the importance of telehealth as a vital component of patient care when many healthcare practices and facilities closed their doors to nonemergency treatment. Although the use of telehealth has receded from its peak during the pandemic, it almost certainly will remain a critical tool in healthcare delivery — particularly since access to care remains a top concern.

Considering how telehealth might benefit patients, but also create challenges, is an important priority for healthcare providers. A persistent concern with telehealth has been the effect of technology on the provider-patient relationship, and whether the digital divide will be detrimental to providing personalized care. To address this issue, numerous organizations have offered guidance on incorporating telehealth, communicating during telehealth appointments, and implementing “telehealth etiquette” standards to improve quality of care and the patient experience.

Healthcare providers who plan to start using or continue using telehealth services should consider reviewing their current telehealth practices for potential improvement opportunities. Examples of recommendations include guidance in the areas presented below.²

Standardization

Like other aspects of healthcare, standardization is important when implementing telehealth to ensure a consistent, fair, and well-reasoned approach. To that end, consider adopting an algorithm or decision tree to help determine when, and for what services, telehealth visits are appropriate. Apply the algorithm consistently within your practice, and develop workflows that help facilitate telehealth encounters.

To ensure further consistency in approach, develop patient selection criteria for the different types of telehealth services offered. Although certain services might be appropriate to conduct via telehealth for some patients, other patients might require a physical office visit. For example, telehealth might not be suitable for patients who have difficulty with technology, patients who have cognitive disabilities, or patients who have multiple diagnoses that require in-person assessment.³

Technology

A digital experience is only as good as the technology on which it relies. When investing in telehealth technology, evaluate the quality of the equipment (e.g., cameras and microphones) and the ease of the user interface. Poor quality or overly complex equipment can lead to distractions, glitches, and miscommunication — all of which can negatively affect the provider-patient encounter and could potentially increase the risk of adverse outcomes.

Privacy and security also are important considerations with technology, as research has identified privacy concerns as a barrier to telehealth adoption.⁴ To address these concerns, select HIPAA-compliant technology and explain to patients the safeguards that have been put in place to protect them and their health information. (Note: Although telehealth regulations were eased during the COVID-19 pandemic, the public health emergency expired on May 11, 2023. The U.S. Department of Health and Human Services Office for Civil Rights provided a 90-day transition period for covered healthcare providers to comply with the HIPAA Rules with respect to their provision of telehealth. The 90-day period ended on August 9, 2023.⁵)

Education/Training

Technology can be intimidating, frightening, or confusing for some patients. Thus, investing effort in educating patients about these services and setting realistic expectations is prudent. For example, in some instances, patients might want telehealth appointments for situations that warrant in-person visits. Other times, patients might be reluctant to use telehealth even though it would be beneficial.

Discuss with patients which services and types of appointments are available through telehealth (based on the aforementioned algorithm/decision tree and selection criteria), and assure them that the practice is dedicated to providing high-quality care during telehealth encounters.

Like any new technology introduced into practice, telehealth presents risks if it’s not used appropriately. Hence, education and training on telehealth also are critical for the healthcare team involved in facilitating and conducting telehealth services. Consider participating in training in preparation for handling both the technical and human aspects of telehealth encounters. For example, running mock patient appointments can help the team become comfortable with digital communication and troubleshoot any technical glitches.

Physical Space and Appearance

Physical space might seem like a less critical aspect of telehealth than other factors, such as workflows and technology training. However, the physical space that the patient sees can set a lasting impression of the entire telehealth encounter and might shape the patient’s view of the value and credibility of telehealth services.

To reinforce that telehealth doesn’t diminish professionalism or the quality of care, evaluate the space in which you conduct telehealth visits to ensure it reflects a professional environment and is neat, clean, and devoid of distracting items. Take care to ensure that no confidential or proprietary information is visible to patients (e.g., on a white board in the background). Dress in professional attire that reflects the style of dress that patients would see if they visited the office in person.

From a logistical standpoint, make sure the physical space has appropriate equipment in place and adequate lighting for clinical assessments.

Preparation

Taking time to prepare for each telehealth appointment can help set the stage for effective and personalized communication. To properly prepare, review each patient’s record in advance to familiarize yourself with the patient’s history, problem list, and chief complaint. Make an effort to be on time or a few minutes early to get settled. If you are running behind schedule, have a staff member notify patients so they are not left wondering if a technology failure has occurred.

Keep the patient’s contact information on hand during the telehealth appointment in case the audio fails or the entire system goes down. A quick call to the patient can alleviate confusion and frustration as well as provide a follow-up plan for continuing the appointment.

Verbal and Nonverbal Communication

Communication is important in every aspect of patient care, but particularly when the provider and patient are not face to face. A study on human factors in telehealth noted that, “In a telemedicine encounter, psychological and technical ‘filters’ may provide additional challenges to the development of effective communication.”⁶ Various verbal and nonverbal communication strategies can help address these challenges.

For example, during telehealth appointments, maintain eye contact with patients as much as possible to establish a connection and reinforce that you are paying attention. Limit interruptions and possible disruptions, and ask each patients if they can see and hear clearly before proceeding with the appointment. Be aware of transmission or “lag” time, and pause briefly to allow patients to respond.

Additionally, general standards for courteous and effective communication apply in telehealth just as they do for in-person care. For example:

• Greet patients and introduce yourself if you have not previously met; ask patients how they would prefer to be addressed.
• To help focus visits, ask patients what they are most concerned about, and allow them to speak without interruption. Repeat their concerns back to them to validate your understanding.
• Use clear and concise language, and avoid medical jargon and complex terminology.
• Use nonverbal cues — such as nodding your head — to show you are listening.

As the appointment progresses, explain to patients what you’re doing, particularly if you have to break eye contact. Patients might not have the same field of view as they would during an in-person visit, so routine tasks (such as documentation) might be misconstrued as distraction.

Before the appointment ends, provide a clear course of action and “next steps” (e.g., treatment instructions, prescriptions, and follow-up consultation). Ask the patient if he/she has any questions or needs any further clarification.

Quality Improvement

Measuring success is no less important for telehealth services than for other aspects of clinical care. Following telehealth appointments, request patient feedback and measure satisfaction related to various aspects of the telehealth encounter, such as ease of technology, quality of the platform, effective communication, etc. Review the results with staff members and incorporate telehealth metrics into your practice’s quality improvement initiatives.

In Summary

Telehealth remains an essential tool for healthcare delivery, and it will continue to serve as a solution for addressing issues related to public health safety and access to care. Careful planning in relation to implementing telehealth services, educating patients and staff members, and developing communication strategies can help create positive telehealth experiences for both patients and providers.

Endnotes

¹ American Medical Association. (2020, February). AMA digital health research: Physicians’ motivations and requirements for adopting digital health; adoption and attitudinal shifts from 2016 to 2019. Retrieved from https://www.ama-assn.org/system/files/2020-02/ama-digital-health-study.pdf; American Hospital Association. (2019, February). Fact sheet: Telehealth. Retrieved from https://www.aha.org/factsheet/telehealth

² American Medical Association. (2020). Telehealth implementation playbook. Retrieved from https://www.ama-assn.org/system/files/2020-04/ama-telehealth-playbook.pdf; Greiwe, M. (2019, March 30). Telehealth etiquette — Conducting the virtual visit. OrthoLive. Retrieved from www.ortholive.com/blog/telehealth-etiquette-conducting-the-virtual-visit; Bulik, R. (2008). Human factors in primary care telemedicine encounters. Journal of Telemedicine and Telecare, 14,169-172. doi: 10.1258/jtt.2007.007041; Wetter, D. (n.d.). A guide to virtual visits with your telehealth program. Health Recovery Solutions. Retrieved from www.healthrecoverysolutions.com/blog/virtual_visits_best_practices; Raymond, R. (2020, April 1). How to do telemedicine in the time of COVID-19. The DO. Retrieved from https://thedo.osteopathic.org/2020/04/how-to-do-telemedicine-in-the-time-of-covid-19/; Wicklund, E. (2016, November 3). A telehealth primer: 5 tips to making the virtual visit a success. mHealth Intelligence. Retrieved from https://mhealthintelligence.com/news/a-telehealth-primer-5-tips-to-making-the-virtual-visit-a-success; Telehealth Resource Center. (2018, January). Telehealth etiquette checklist. Retrieved from https://telehealthresourcecenter.org/wp-content/uploads/2020/11/Telehealth-Etiquette-Checklist.pdf; Sikka, N. (n.d.). Telemedicine: Can it help your practice? Medscape Academy. Retrieved from www.medscape.com/courses/business/100021

³ Sturesson, L., & Groth, K. (2018). Clinicians’ selection criteria for video visits in outpatient care: Qualitative study. Journal of Medical Internet Research, 20(11), e288. https://doi.org/10.2196/jmir.9851; American Medical Association, Telehealth implementation playbook.

⁴ Scott Kruse, C., Karem, P., Shifflett, K., Vegi, L., Ravi, K., & Brooks, M. (2018). Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare, 24(1), 4-12. https://doi.org/10.1177/1357633X16674087;

⁵ U.S. Department of Health and Human Services Office for Civil Rights. (2023, April 11). HHS Office for Civil Rights announces the expiration of COVID-19 public health emergency HIPAA notifications of enforcement discretion. Retrieved from www.hhs.gov/about/news/2023/04/11/hhs-office-for-civil-rights-announces-expiration-covid-19-public-health-emergency-hipaa-notifications-enforcement-discretion.html

⁶ Bulik, Human factors in primary care telemedicine encounters.

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