Discussion
In this survey-based study of 247 providers who had used telehealth in 2020, we identified variations in the experience and expectations of VV along with three main themes from qualitative analysis: infrastructure and training, usefulness and expectations. These findings could have implications for how healthcare systems, clinicians and patients can best move forward with organising and delivering care augmented by technology. A key question also emerges: if patients desire the convenience of virtual care but there are drawbacks, how should those decisions be adjudicated? We reflect on patient-centred care, how care may be organised differently and infrastructure changes encouraged by clinicians. Lastly, we briefly reflect on how our clinical organisation is moving forward with embracing virtual care while enabling clinical departments to determine how best to proceed.
Patient-centred care
Overall, clinicians generally felt comfortable with telehealth, signalling more could be done virtually with the appropriate and proper support. Clinical confidence was high among respondents, and 56% noted that they could see 39% of their patients virtually. This supports the growing trend of new modalities of care to continue to be built around the patient, wherever they are. However, not all clinicians agreed with the usability of telehealth and the ability to use technology to accomplish visits with effectiveness, efficiency and satisfaction in a care context. Undoubtedly, context is critical; facilitating the selection of the ideal medium of a visit—either in-person or mediated by technology—for patients and providers alike will ultimately be a key factor in integrating technology. The nuanced data indicate that organisations must take a customised approach to deploy telehealth across ambulatory care. Not all patients, clinical departments or diagnoses are appropriate for telehealth. For example, telehealth may be inappropriate for encounters when a hands-on physical examination is necessary to manage care.15 Deciphering optimal telehealthcare will depend on the specialty,16–18 making a one-size-fits-all approach untenable.
Clinicians lauded the insight gained via telehealth into a patient’s life circumstances. Prior work19 highlighted similar insights that previously invisible patient contextual factors came to light during telehealth visits. This was, however, at times uncomfortable. Clinicians reported patients taking telehealth visits in inappropriate settings (eg, while driving, in public) and at times citing that patients do not respect a VV as much as a doctor’s in-person visit. Some ended the VV when patients refused to stop driving or were shopping. While this may be prudent for safety and privacy reasons, we reflect on the patient perspective. Patients may perceive the convenience of having a visit while completing other tasks as appealing, though we acknowledge that privacy within shared spaces may limit what can be shared. Telehealth creates new friction, one where the healthcare system must fit into the patient’s life, rather than the usual dynamic of the patient fitting into the physician’s office. Therefore, telehealth is pushing the boundaries of patient-centred care, and new improved measures of education on safety and training of practitioners to handle those non-traditional situations will be important.
Clinical care organisation
Telehealth creates several opportunities to change the care model. For example, clinicians identified how initial encounters, mostly history-taking and data review, could be done virtually and then shift to gaining objective data in subsequent in-person visits. Patient needs may be more effectively triaged using video, ensuring that patients present to the most appropriate level of care. Pharmacists, nurses and other care team members may leverage video to better relate to patients, reconcile medications and identify additional needs. Clinical organisations could optimise the unique benefits of telehealth to further their value-based care work or more appropriately use in-person care in fee-for-service contracts where access to providers is limited.
Respondents highly endorsed other important benefits of reducing infection risk, eliminating travel time and removing transportation challenges which can be very limiting for patients and providers.20 21 Removing transportation as a critical step to seeing the provider may reduce health inequities by granting individuals access to the healthcare system regardless of their ability to commute.22
We identified through the survey areas where telehealth has opportunities to improve the work–life balance of clinicians. About half of our survey respondents identified that having clinic blocks where they could work from home was extremely important. Healthcare systems should find ways to organise care blocks to support flexibility, especially in current challenges facing healthcare workforce shortage,23 and ensure that clinicians are adequately compensated for the telehealthcare they provide regardless of payment changes.
Infrastructure, workflow and training requirements
Telehealth infrastructure and patient and clinician technological acumen continue to evolve. Respondents noted technological hurdles (eg, unreliable platform and lack of tech support) diminished the efficiency and effectiveness of care. In particular, clinicians had difficulties logging onto the VV platform and related technological issues. Many of the recent telehealth studies report similar technology-based challenges.16 19
Future directions of telehealth should focus on improving the user experience and reliability of the telehealth platforms,24 developing a consistent workflow tailored by specialty and creating training, support and knowledge resources. Visit experience will be improved if patients are screened for reliable connectivity, access to devices, expectations of telehealth and ability to navigate the telehealth platform, with the option to switch to other modalities if any issue arises.25 26 Other organisations have been using medical assistants and community health workers to conduct a previsit assessment before the first VV with a clinician to screen for digital literacy and subsequently improve the success of their VV.25 27
Clinicians in our study and elsewhere9 17 19 reported they could benefit from additional telehealth training to understand what care works best in a virtual delivery format. Clinicians are used to being supported in the clinical setting by a multidisciplinary team (eg, medical assistants, nurses and social workers) but often lack such support in the virtual setting. The adjustments caused frustration among clinicians citing inefficiencies in the digital prearrival, check-in and rooming processes. Healthcare systems must create clinic protocols that incorporate a team to be effective and efficient in the virtual space.28 Supporting patients capable of self-check-in may create inefficiencies and waste resources, however. Instead, there needs to be an adaptive process that enables patients to complete a self-check-in while ‘catching’ patients who need help getting connected.
Future directions
In our healthcare system, these data and the qualitative analysis have informed our planning, goal setting and investments in telehealth. For infrastructure, we have invested in redesigning the experience of VV to enable patients to complete the prearrival process independently when possible, making it more efficient for clinicians to conduct visits without needing an assistant. However, a core requirement was the ability to send a patient a direct link by text message for patients who need extra support. Workflows were redesigned to support these use cases.
We have set a practice target to increase our VV to meet patient expectations at the department level. A practice committee developed a playbook for departments to review and determine how they may best use telehealth. Importantly, we committed within the practice that if the reimbursement landscape changes, strategies and targets would be adjusted accordingly.
Limitations
Although this study provided telehealth insights from clinicians across ambulatory care specialties, limitations exist. We asked clinicians to reflect on their perceptions and experiences with virtual visits during the PHE. They may have recall bias,29 where respondents’ memories deteriorated and their ability to recall their perceptions and experiences diminished. The clinician population recruited was limited to one academic-community health network in the Midwest. However, the network includes clinicians practising in academic and community settings and rural and urban locations. Furthermore, most respondents identified as middle-aged white women, limiting the generalisability to more diverse clinician populations. In addition, the survey had a 50% response rate, which is at or better than typical clinician surveys;30 however, we could not discern the characteristics of the non-respondents to evaluate for differences between them and the respondents. Moreover, the quantitative findings are unweighted frequencies which may introduce response bias. Additionally, the survey was not validated as part of this study, although the questions were derived from a well-established implementation science framework.14 Finally, the clinicians’ insights reflect interactions with patients who accessed telehealthcare. We acknowledge that this is a subset of the patient population.12