Are You With the Herd or Just Looking On?

For most people, there is safety in numbers and following what the majority of other people (or, especially in the US, other people like you) are doing, must be okay and safe to do as well.

The problem is when what other people are doing is done behind closed doors, invisible to the other members of the herd. Then the adoption of a new behavior is trickier, because without the visual cues of seeing other people “doing it”, falling into “herd mentality” is much harder.

Before you are trying to figure out what people may be doing in hiding, let me remind you that this is a column about telehealth and digital health — and therefore my point is that most telehealth visits occur, well, behind closed doors.

When it comes to delivering care, conducting a physical exam, or leading a counseling session, most clinicians’ behaviors are imprinted early on in their education, refined through feedback from mentors in the early years, and then honed over years of (mostly) isolated experiences. There is typically little to no supervision as to what happens when that exam room door closes. It’s up to the professional experience of the clinician.

This is especially true for the most common flavor of virtual care / telehealth / telemedicine: video visits. Similar to in-person visits, they are conducted “in private” barely even visible to the other clinicians in the same clinic, let alone to clinicians in other clinics or other locations.

It’s an example of the proverbial echo chamber where you only see and experience what you see and experience, not realizing what others around you are doing.

What the Telehealth Herd is doing

One of the first state-wide organizations to promote the use of telehealth was the Virginia Telehealth Network, established in 2006. In the wake of the Covid-19 health crisis they conducted a Telehealth Usage Benchmark Survey in 2021 and just recently repeated the survey in 2023, which generated responses from over 10,000 active licensed healthcare providers in the Commonwealth of Virginia.

The key findings of the 2023 Benchmarking Telehealth Usage Report for me were that Telehealth is used by over 75% of the providers seeing patients. If that’s not a herd, than I don’t know what is.

Staying with the herd, the majority cited a number of positive benefits of telehealth such as the mere ability to offer current patients a virtual care option (89%) and the ability to enhance care coordination for patients (62%).

But telehealth also provided opportunities for growth to serve new patients within the community (57%) and from beyond the local community (52%). In terms of access to care and improving the sustainability of healthcare’s fragile business model, these numbers are exciting to see.

Many providers also agreed or strongly agreed with the following benefits, that telehealth allows them…

• …to address patient care barriers (87%)
• …to see more patients (76%)
• …to have more flexibility in their schedule (84%)

What’s even more impressive is that telehealth is now showing demonstrable results regarding the quality of care and outcomes, with 80% agreeing that they have “seen improvements in patients’ continuity of care due to telehealth” and only 3.9% disagreed with the statement that “Telehealth is an effective tool for providing care to my patients.“

Equally encouraging was the future outlook: 61% plan to increase telehealth usage in the future and 88% realize that “patients would be disappointed if [they] stopped offering telehealth appointments.“

One caveat though is in the makeup of the respondents: about half (47%) of the respondents are medical/behavioral health providers and only 10% are providing primary care. Assuming that the data my be skewed towards those who opted to respond because they do have an interest in telehealth, there is definitely still room to grow beyond behavioral and mental health.

What the Onlookers are concerned with

Of those not using telehealth, the concerns varied, with the majority (56%!) claiming that they don’t use telehealth because it is “not compatible with specialty/practice style”. In the context of the University of Virginia offering telehealth in over 45 specialties, that sounds like a red herring. True, Telehealth is not a fit for every visit, but to categorically reject telehealth as an option sounds more like resistance to change in the face of evidence to the contrary.

Even more disheartening is that 44% said they would not consider any aspect of telehealth in the future. In the context of the telehealth-practicing providers’ insights into the patients’ disappointment of taking telehealth away, that attitude against telehealth looks like a first step towards extinction. Thankfully at least 35% were open to scheduled video visits, so there’s hope for some.

While the numbers are small (less than 1 in 8), other reasons cited against telehealth use were the quality of care (12.4%), lack of patient demand (11.9%), and the patient’s technical limits (11.5%).

Thankfully two of the top 5 pre-pandemic reasons (collected by the AMA in 2019) are no longer a big concern: the liability when practicing medicine via telehealth (6.2%) and reimbursement (7.7%).

The herd’s outlook

While liability and reimbursement are not the primary excuses, err, reasons for not providing telehealth, they still rank high on the list of areas where improvement is needed as indicated by 37% and 59%, respectively.

Interestingly, and it’s showing the maturity of how far we’ve come and how far ahead we are thinking (literally), the main aspect for improvement is interstate licensure – the ability to care for patients when they are crossing state lines, which especially in border areas is important. Virginia borders 5 states and DC and 37% of Virginia’s population lives in the Northern Virginia area that is close to DC and Maryland.

On the patient side, improving patient connectivity (74%) was definitely top of mind for most, followed closely by the need for devices (55%) and technical assistance (55%).

Where do you stand?

So, are you an onlooker (chances are that if you are reading this column, you are not) or part of the herd (or even a trailblazer?). If you have some onlookers in your clinic, people being skeptical about this “telehealth thing”, then maybe this report may provide some evidence to the contrary.

But numbers won’t mean a thing, because logic makes people think. It’s emotions that make people act, so my suggestion is to point to the patients’ expectations of having access to care and the notion that it can increase the continuity of care and therefore care outcomes. If they haven’t lost their love of medicine, that should give even the most ardent opponent to telehealth cause for pause.