Doing Telehealth Right: How to Implement Telehealth Without Ruining Patient Engagement

So, after writing my last piece on the hidden dangers of telehealth, I’ve had several clinic owners, directors, and clinicians reach out and ask about how to avoid the potential dangers and pitfalls that lurk in the shift into telehealth and virtual service delivery models. One thing is certain: telehealth is not going away. It simply provides too much convenience, access, and cost reduction to simply fade into the background.

So, the question becomes, if telehealth is going to be a permanent part of healthcare delivery in the future, how do we leverage its benefits without falling victim to commoditization and amplified negative patient experiences?

Here are some preliminary thoughts on the matter.

Telehealth Done Wrong: Commoditization, Downward Pricing Pressure, and Negative Patient Experiences

The biggest risk that telehealth poses to clinics and clinicians relates to the possibility of commoditization. Simply put, if telehealth is implemented improperly, it can reduce the perceived value of the services being provided. But let’s explore this a little more deeply. How exactly could telehealth lead to a reduced perception of value of our services by clients and patients? 

Tech Issues: Zoom Fatigue, Interpersonal Communication Challenges, and Glitches

As many have written about recently, video & virtual teleconferencing may require more energy & focus than in-person interpersonal interactions. In fact, the Harvard Business Review recently published an article on “How to Combat Zoom Fatigue“. The article discusses how distractions are much more tempting and prevalent in the virtual world. This holds true for telehealth, on behalf of the clients and the clinicians. We’ve all done it: nodded along, saying “Yeah. Hmm…sure.” while we’re on a video call while simultaneously checking our email, texting a colleague, and/or doing a quick search on our computer or over the internet for a piece of content or resource that might be helpful in that conversation. The only problem is that those tasks prevent you from being fully present in the conversation, from truly listening to what is being said, and from actually being able to pick up on subtle cues being left by the speaker. Now imagine that you, or your client, are engaged in this sort of multitasking during a treatment session or assessment. What gets missed? What impression does it leave the client when it’s apparent that their clinician isn’t 100% focused on them and their situation?

In addition to zoom fatigue, there’s something more out of our control in the virtual healthcare space that has the power to negatively impact patient engagement & experience: lag, tech glitches, and other factors associated with virtual communication. As discussed previously, communication between clinician and patient/client greatly impacts patient engagement, retention and experience. Put simply: interpersonal interactions and communication between clinicians and patients can have just as great an impact as the clinician’s skills or knowledge. That said, what happens when tech issues prevent efficient communication between patients and clinicians? As one 2014 study suggested, delays in conferencing systems shape our views of people negatively [5]. In fact, a delay of 1.2 seconds can make your patients perceive you as less friendly or focused. In other words, a technical problem (outside of your control) can cause a patient or client to attribute their negative experience to your personality or behavior.

To understand this, you need to understand a bit about speech quality assessment. Speech quality is defined as “the result of a perception and judgment process, during which the listener establishes a relationship between what he perceives (i.e., the sound event) and what he expects (i.e., the internal reference): speech quality is not absolute, but is attributed by the listener.” [3]. It’s important to note that speech quality is entirely subjective. Your patients and clients determine what is high quality and what is not. As I’ve written about here, the environment or context affects our expectations. Our expectations influence our perception. And our perception affects what we experience, how we experience it, and the thoughts, choices, or actions that result from that experience.

Understanding this, it becomes clear how video lag, freezing, & delays can negatively impact your patient’s views of your skills, your clinic, and even your ability. The presence of some tech issue negatively influences your patient’s expectations and perceptions, which ultimately affects their experience during your telehealth session. In fact, a report published by Hewlett Packard discusses how physical gestures and even breathing is considered an integral part of the communication experience [2]. Again, lag, latency, & freezing video impacts your patient’s ability to pick up on those cues (and also prevents you from doping the same).

Negative Patient Experiences are Magnified in the Virtual Space

As some of the research mentioned above suggests, negative patient experiences can actually be magnified in the virtual or telehealth space. Why? Because outside of the context of in-person (or in-clinic) conversation and interactions, your patients rely on their experience of the virtual space. This includes those factors mentioned earlier as well as others that may impact their perception of the quality of services being rendered. Take something as simple as the platform you choose to provide your telehealth treatment. How user friendly is it? Even if it is user-friendly, have you provided sufficient information and education to your patients and clients about the platform prior to initiating a session? What if you don’t check and ensure that your patient is good to go on a platform before an appointment?

Think of it like this: You call the customer service line for your internet provider (we’ve all been there). The internet crashed or froze up and you need to speak with someone about getting it up and running because you can’t check in new patients, document in your EMR, or send any correspondences to patients or referring providers. You call the number and an automated answering services greets you. “For customer service press 1.” You press 1. “For problems with internet services, press 1.” You again, press 1. “By pressing 1, you have indicated that you are experiencing some trouble with your internet connection. Is this corset?”. Through gritted teeth, you say, “Yes.” You hear, “One moment…let me do some more digging to see what the problem is.” Now, for the next 15-20 minutes, you engage in a series of questions, answers (and sometimes repeated answers), until the automated machine finally says, “Hold on. Let me connect you to someone who can help.” Now you’re thinking, what’re heck! You just wasted 20 minutes of my life and I still don’t have internet! 

Now a real person answers the phone, they ask you basically all the same questions the computer asked you over the past 20 minutes. Then they do a little IT jujitsu and you’ve got internet again (maybe they asked you to turn your router off and then back on). While you may be happy to have internet back up and running, have you had an overall positive experience? Of course not. I would even go so far as to say that the experience is actually worse than it could have been if you were able to sit in front of the customer service or IT tech and say “This is what’s going on. Can you fix it?” Why is that? Because humans are social creatures and we rely heavily on interpersonal communication and signals to convey information. But it also feels like a huge waste to have to go through the runaround of the automated system.

Now take that same scenario and substitute internet problems for back pain, shoulder pain, anxiety, stress, or any other issue or diagnosis you may treat in your clinic. If our patients don’t understand how to use the platform you’ve selected for telehealth, or if certain aspects of care aren’t appropriate for telehealth, you’re essentially putting your patient in the role of calling that automated machine. They’ll get frustrated, angry, irritated, and will likely have a negative overall experience of the session. Add to that the inability to interact in-person with you, the clinician, and it can all lead to a worse experience than having a few glitches like increased wait times at your clinic.

Passive Treatments: Effective in the Short-Term, Damaging in the Long-Term

Now, the tech issues all relate to your patient’s experience of a telehealth session. But what about the valuepiece? Unfortunately, even in the clinic, many organizations and providers rely on low-value, passive treatment techniques. These techniques may temporarily relieve your patient’s symptoms in the moment, but they offer very little in the way of continued management of their own health, condition, or limitations after they leave your clinic. But let’s take a step back and define passive treatments. According to the literature, passive treatments “require the patient to be a submissive recipient of treatment.” [6]. This could include anything from manual techniques, trigger point release, ultrasound, other physical agent modalities; basically any treatment where you do something to the patient. What’s so wrong with that? Well, the research indicates that passive treatments, if used as the primary focus of treatment, may actually reinforce your patient’s feelings of helplessness or powerlessness and put the responsibility for management of their condition in your hands, as their clinicians [6].

Now, I want to say that I’m not telling you to throw out all of the techniques you’ve learned over the course of your schooling and career. Often times, passive techniques can be a great adjunct to treatment, and can even be used to get a patient over the initial pain or discomfort of beginning treatment. That being said, you shouldn’t rely of passive treatment techniques with your patients, as they may ultimately have negative long-term affects on your patients. And that holds true for in-person or virtual models of healthcare service delivery.

And on top of the clinical implications of relying on passive treatment techniques, there’s the impact of patient perceptions of them in the virtual space (or your ability to even provide them over the inter webs). For example, if the patient experience in your clinic relies too heavily on those passive treatment modalities, what happens when you and your patient find yourselves in a virtual environment, where passive treatment techniques may not even be an option? As one clinic owner recently told me in a conversation, “they [the patients] just don’t see the point in paying for telehealth if they’re not going to receive any ‘hands-on’ treatment.” He brings up a good point here: if you’re relying on passive treatment approaches, your patients will likely (and rightly) feel that there simply isn’t value in signing up for telehealth.

It also opens the door to downward pricing pressure, commoditization, and maybe even challenges with third-party payers. If what you’re offering is run-of-the-mill services, there’s nothing to differentiate your practice or clinic from the one down the street. It makes you compete on price (if you’re cash-based or out-of-network) and also gives more power to third-party payers to set lower reimbursement rates for your telehealth services.

Doing Telehealth Right: Offering High-Value, High-Impact Services

Ok, now that we’ve covered all the ways things can go wrong during a telehealth experience, let’s look at how to do it right by offering high-value care in a patient-centered (or person-centered) manner. Like it or not, telehealth is here to stay. Patients expect it now. Healthcare providers and hospital systems are noticing its benefits from a cost & access standpoint. And CMS has established a precedent for telehealth moving forward.

That being said, you can’t simply apply “standard” or in-clinic practices and procedures to the telehealth or virtual service delivery world. The change in delivery method, treatment environment & context, as well as patient & client expectations all dictate that you learn to take your highest value services & treatment techniques and adapt them for the virtual world. Let’s start with client expectations.

Client & Patient Expectations

As mentioned previously, our expectations influence our perceptions, which in turn influence what we experience and how we experience it. Many times, your clients already have expectations in their minds about how treatment should look, the types of interventions they may receive, and the results they’ll experience in your clinic. Now, if you don’t address client expectations at the outset of a course of treatment, you risk the client becoming dissatisfied, unhappy, disengaged, and possibly even angry with the experience they have in your clinic. Regardless of whether you are seeing patients and clients in the clinic or over the interwebs, managing patient expectations should be a top priority.

Often times, patient expectations about the type of treatment they’ll receive impacts their experience in your clinic. What do I mean by that? Well, how many patients have you seen in your clinic that expect you to “do” something to/for them to relieve their symptoms? Just give me a pill, crack my joint, massage this muscle, stretch me here… the list goes on and on. The problem with these expectations stems from an underlying view of healthcare. As I’ve written about here, for the vast majority of medical history, we relied on a biomedical model of treatment. This model rests on the idea that injury, illness, or disease stems from biological or anatomical dysfunctions. It doesn’t take into account the social, environmental, and even psychological factors that can be at play in a patient’s specific situation.

Often times, either in-clinic or over the web, your patients may still hold many expectations and beliefs about treatment based on this biomedical model. That being said, your goal should be to provide education and communicate in a way that is both empathetic & understanding, but also reframes their expectations about treatment, outcomes, and recovery. This often involves a discussion about the difference between active & passive treatments. The literature shows that true, high-value treatment is based on active treatments (self-management skills, mindfulness, active movement, etc.) provides better long-term clinical outcomes than passive treatments (medications, manual therapy, surgery, etc.) [6]. Especially in the virtual space, where passive treatments can’t easily be delivered or provided, you must reframe patient expectations about the value of active treatments.

Self-management

As mentioned above, self-management skills and techniques provide better long-term outcomes than passive treatments. I’m not saying there’s anything wrong with passive treatments, especially if used in a way to encourage or facilitate participation in an active treatment. But I am suggesting that the core components of treatment plans should be based on providing patients with the skills, techniques, and strategies to manage their own health and recovery.

This focus achieves 2 goals: 1) it empowers your patient to become the driver of their own health and well-being and 2) it decreases clinician (or medical) dependence. It fundamentally alters the relationship you have with your patients. No longer are you the person that can put heir back “into alignment” or “adjust” their neck, or “massage” their sore muscle. Taking a self-care and self-management approach, to treatment, you become a guide and trusted resource to your patient, who is now motivated and taking control of their own health. Your patients begin looking at you as a coach or accountability partner, as well as a trusted advisor on matters related to their health (not just the diagnosis that originally brought them to your clinic).

Education

Continuing on with the theme of active vs passive treatment, and delivering high-value care via telehealth, you must consider patient education. The type of education you provide to your patients, especially in the telehealth environment should “facilitate active engagement approaches (targeted exercise therapy, physical activity, and healthy lifestyle habits) and reduce reliance on passive interventions.” [1]. If self-management, active treatment, and the like offer the highest form of value to patients, then you should educate your patients with that type of information. Especially in the telehealth environment, where a patient might not “see the point” of attending if you can’t physically stretch, touch, or feel the area of pain or dysfunction, you must address these expectations through proper education at the outset of assessment & treatment.

Encouragement, Coaching, & Empowerment

Unfortunately, many clients and patients that show up to clinics across the country tend to value short-term relief at the cost of long-term outcomes. This, again refers to the seemingly universal desire on the part of patients to receive some treatment or intervention. This is likely due to the fact that, at least for the vast majority of the healthcare industry’s existence, clinicians and organizations have reinforced the idea that passive treatments are the standard of care [6]. Simply put: most patients that walk into your clinic expectyou to do something for/to them to relieve their pain, take away their symptoms or dysfunction, etc. 

That’s one reason why taking an educational, empathic, and encouraging approach to patient care plays a vital role in helping improve outcomes, engagement, and satisfaction scores. You must address a patient’s expectations early, at the beginning. You should use education as a tool to help patients understand that your ultimate goal is to help them overcome whatever limitation, pain, or symptoms they are currently experiencing by giving them the resources, skills, and support necessary to do so on their own. You can certainly use passive treatment modalities as an adjunct to active treatments, self management, and the like. But your patients need to understand that your role in the process is to provide the necessary encouragement, support, and assistance to empower them to take control of their own health and well-being. You’re a coach, a mentor, a guide; not a handyman or Mr. Fix-it. 

Patient Experience: Interpersonal Interactions & Building Relationships

One of the many benefits of taking this approach to healthcare service delivery becomes apparent over the course of care, and then in returning patients: real, lasting relationships with your patients and clients. When passive treatment modalities remain the core service offering at your clinic, the interaction you have with your patients stays at a merely transactional level. The patient comes in. You do your thing. They feel better and leave. They come may or may not come back again, depending on how they’re feeling. That’s it. 

Now, I always say that clinicians that get into this field typically posses great people skills. They build relationships easily, are warm, welcoming, and inviting; and their patients genuinely value the relationship they have with them. However, this relationship often times stays in the superficial. They may open up about their shoulder pain, how it’s impacting their day-to-day living, and their hopes for recovery. They may even share about their family, social life, etc. But when the focus of the interaction is on this “pain” or “symptom”, the relationship doesn’t grow deep roots. 

However, when the focus of the interaction is on empowering your patient to take the driver’s seat in their own health and well-being, the relationship blossoms. No longer are your appointments and interactions simply transactional. You now become a trusted advisor, mentor, coach, or whatever term you like. You become the trusted guide, helping your patient achieve their ultimate goal of a full and healthy life. That means you see greater impact in your work, your patients value you more, and you build long, lasting relationships with them. They’ll not only think of you the next time their shoulder hurts, but they’ll also think of you when they have some health or lifestyle change they want to pursue. 

Summary

Ultimately, you need to understand that telehealth & virtual healthcare delivery models are here to stay. The key to diving into that world lies not in the technology, or the interface, or the format —although you should try to get those squared away. The key to implementing telehealth is to remember what your true high-value services are. Your high-value, high-impact services are your ability to encourage, guide, and empower your patients into taking the driver’s seat in their own health and well-being. It lies in your ability to build true, lasting relationships that can be used to support your patients as they make these behavioral changes, and in helping them develop the self-management skills they’ll need to stick with them. Telehealth might limit your ability to physically touch, assesses, and interact with your patients, but that constrain forces you to lean into the true value that you, as a clinician can provide.

What are your thoughts on Telehealth and virtual healthcare delivery? Do you think the constraints telehealth places on clinicians & clinics can lead to greater impact in the long-term? Share your thoughts in the comments below!

Resources:

[1] Caneiro JP, Roos EM, Barton CJ, et al. It is time to move beyond ‘body region silos’ to manage musculoskeletal pain: five actions to change clinical practice. Br J Sports Med. 2020;54(8):438‐439. doi:10.1136/bjsports-2018-100488

[2] Geelhoed, E., Parker, A., Williams, D., & Groen, M. (2009). Effects of Latency on Telepresence. HP Laboratories.

[3] Guéguin, M., Bouquin-Jeannès, R. L., Gautier-Turbin, V., Faucon, G., & Barriac, V. (2008). On the Evaluation of the Conversational Speech Quality in Telecommunications. EURASIP Journal on Advances in Signal Processing,2008(1). doi:10.1155/2008/185248

[4] Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. Br J Sports Med. 2018;52(24):1543‐1544. doi:10.1136/bjsports-2018-099198

[5] Schoenenberg, K., Raake, A., & Koeppe, J. (2014). Why are you so slow? – Misattribution of transmission delay to attributes of the conversation partner at the far-end. International Journal of Human-Computer Studies, 72(5), 477-487. doi:10.1016/j.ijhcs.2014.02.004

[6] Cosio, D., & Lin, E. (2018). Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Global advances in health and medicine, 7, 2164956118768492. https://doi.org/10.1177/2164956118768492