…and what to do about it.
When your organization finally embraces telehealth, recognizing it as a critical strategic tool to give your “modern healthcare consumers” (a.k.a. patients) what they want (i.e., convenience) you’re still left with a problem.
How do you convince all of your clinicians to accept virtual care delivery as a valid and viable alternative care delivery modality? How do you engage the nay-sayers and red herring throwers (“my patients don’t want it” or “it’s not good care”) — when you know for sure and first hand that tens of thousands of clinicians are delivering “care at a distance” every single day?
Seek First to Understand, then to be Understood
The seminal book 7 Habits of Highly Effective People by Stephen Covey has been my go-to guide for living a powerful personal and professional life for decades. One of the 3 habits of Public Victory is that we must seek first to understand, then to be understood.
To help you understand where clinicians may be coming from, here are 8 different reasons that I’ve encountered over the past 15 years that describe clinicians’ apprehension to integrate the use of telehealth (especially video visits) in their clinical practice.
1. Sense of loss of control. From the early days of education, clinicians are trained to be confident in their interactions with patients. And in the comfortable world of inpatient care in their exam rooms — with properly roomed patients, a chief complaint and a set of vital signs — clinicians feel in control. But in a virtual environment, where clinicians can’t see what’s behind or beyond the patient, where maybe the video or audio is not clear and they can’t do anything about it, clinicians are like a fish out of the water — not in their element. Which does not create an environment in which a clinician can confidently diagnose or recommend the best course of action.
2. Don’t want to look stupid. Of course nobody likes to look stupid, but the main mindset of clinical care is that, for the most part still, we patients still look to the clinicians as the experts to tell us what’s wrong with us and make us better. But when clinicians fumble with the technology, are nervous about clicking the wrong button, it is hard for them to come across as confident — and hard for us as patients not to be affected by the nervousness. How can I trust my doctor if they can’t even use a computer?
3. Bad experience during Covid. Most organizations not already into telehealth before the pandemic were struggling greatly to properly launch their telehealth services. “Here’s a webcam and a Zoom license, now do telehealth” was the rollout approach and many clinics. Equally ill-prepared were the patients – with cameras and microphones and speakers that did not work, cameras pointing at the ceiling or just their forehead, and repeated sayings of “I can hear myself echoing”, “can you hear me” or “you are muted”. No wonder many clinicians rightfully concluded: “If this is what telehealth is, I don’t want to have any part in this.”
4. Want evidence that it works. While sometimes this request can be a red herring, it was (and still is) an understandable concern. With not having had any experience (and often no preceptor or even peer with any significant telehealth experience), this question was and is on my clinicians’ minds, since “we’ve always done it this way” (in person).
5. Don’t think it’s good medicine. This concern is most often related to the (perceived) inability to conduct a physical exam, even though these days they are mostly a ritualistic and perfunctory part of the primary care check up.
6. Assume patients don’t like it, don’t want it. While there are certainly a number of patients that do not feel comfortable with or suspicious of technology, those patients who do come to in person visits may be the wrong person to ask vs. the patient that does not come in, because it is not easy for them. For those that have the means, the ability, and the time to make it to in-person visits, telehealth does not have much to offer. Contrast that with the two-job working single mom with no child care or no car or no gas money or the elderly patient with poor eyesight who is hesitant to drive in the rain.
7. Concerned about reimbursement. This was mostly a concern before and during Covid, though the thought that telehealth is reimbursed less is still quite prevalent, though it’s only true under a few circumstances, e.g., Medicare patients of an FQHC.
8. Concerned about malpractice claims. This concern relates to the clinicians’ lack of confidence to provide good quality care, or to overlook something that could lead to a negative outcome opening them up for a malpractice suit.
Effectively Addressing the Clinicians’ Concerns
To address the 8 common reasons why clinicians are apprehensive about telehealth, here are 7 tactics on how to address the clinicians’ concerns:
A. Co-design effective and comprehensive workflows: In order to restore clinicians’ control of their patient care experience, the first step is to co-design with the clinicians the experience that they want to have. What should happen before the visit? What should happen during the visit? How do they “find” the patient, let them “in” to the exam room? This also requires the definition of pre-visit processes (scheduling, prepping, and rooming) as well as post-visit processes (discharge, post visit, and billing). For more information, see ”Telehealth and the 7 Thworfs”.
B. Provide Clinician Training on Technology, Workflows, Policies, Webside Manners, and Virtual Exams: People are reluctant to do something if they don’t know how and have never tried it before. The best approach to not let clinicians feel stupid, is to provide training on the telehealth technology, on the aforementioned workflows, on the existing policies. In particular, sharing some of the best practices on “webside manners” and on conducting (and documenting) effective virtual exams. For more information, see “Telehealth Training for Clinicians” and “The 10-fold Return on Mastering Webside Manners”.
C. Talk frankly about the Covid experience. If you can discern that one of the root causes of clinicians’ apprehension about telehealth is the experience they had during Covid, then debrief from that experience. Identify the particular points of frustration and explain how you have or will be addressing them (e.g., through defined workflows, better technology, training, and through Telehealth TechChecksSM for patients). For more information, see “Telehealth TechChecks: Rocketfuel for Telehealth Success”.
D. Share Telehealth Trials, Telehealth Surveys, etc. In order to correct misconceptions about clinical efficacy or patient acceptance of telehealth find articles and reports that are published in the major online healthcare publications. Here’s just a quick sampling: Accuracy of Telehealth Diagnoses, Telehealth Use by Generation, Telebehavioral Health Efficacy
E. Conduct and Share your Own Surveys: In order to address the most critical voices, surveying your patients on their interest in telehealth may be the best way to get a feel for the unique needs of your population across age groups, genders, and zip codes. But don’t just survey your current in-person patients, but try for example also to reach those that may have not had a visit for over a year. The lack of telehealth offerings may be the reason.
F. Measure and share your own data. When it comes to concerns about telehealth utilization or telehealth reimbursement, the best way (and best practice anyway) is to measure and share the data on utilization, satisfaction, and reimbursement. For more information, see this collection of resources on “Measuring Telehealth Success”.
G. Develop Clinical Guidelines for Telehealth Use. Some of the clinicians apprehensiveness can also be attributed to the absence of generally acceptance standards or even guidelines. Even though telehealth has been around for over 30 years, many of the medical associations for the longest time rejected telehealth as second class medicine and that messaging, that many clinicians may have been exposed to during their training, has stuck due to the first impression bias. In addition to workflows, it is crucial for clinicians to sit down under the leadership of the Chief Medical Officer to decide what constitutes circumstances under which telehealth would not be clinically appropriate and where an in-person visit would be needed.
Telehealth is a Clinical Tool
I have yet to meet a clinician who categorically refuses to do telehealth in the presence of emphatically presented evidence of telehealth’s efficacy and broad acceptance and a commitment to “do right by them” through well defined workflows, proper training, and the jointly developed clinical guidelines for appropriate telehealth.
Ultimately it is also important to note that Telehealth is a Clinical Tool. Just like treatment plans and prescriptions, it is up to the discretion of clinicians to wield this alternative care delivery modality as they see best fit for the patient’s condition and the patient’s situation. Oftentimes, the decision is not between in-person and virtual, but between virtual and no visit. And here, a virtual visit should “win” every time.