Introduction
In January 2020, telemedicine represented ∼2% of all visits to healthcare providers in the United States. By June 2020, this figure was ∼80%. This huge leap in adoption was of course spurred on by necessity, as traditional care was impossible, and the entire planet was advised to engage in social distancing, and other risk mitigation efforts, to reduce transmission of the highly contagious respiratory virus that has left more than 6.4 million people dead in the 2 years since a global pandemic was declared. But there is another huge reason for this massive uptick in adoption, without which this would never have happened: patients were happy to engage with providers via this platform.
Physicians and providers know that telemedicine is good for their practice because it is an efficient and convenient way to engage with patients. It can allow them to continue treating and educating those who are unable to come to their clinic. But patients are the ones who decide whether to start or continue using telemedicine. To earn their support, we must address the many reasons why patients may not choose telemedicine. All involved in healthcare can help patients overcome fears and reservations, by providing them with education and by making every telemedicine encounter a good one.
As many healthcare providers may feel intimidated and even overwhelmed with the telehealth process, technical jargon, wearable devices, connection and connectivity issues, so too, do patients. Many physicians and providers should consider that they may also need to adapt to provide not only medical assistance, but also technical assistance, so that their patients can access healthcare.
Helping patients and your practice through organizational change
While the world was presented with a once in a generation moment, which could have catalyzed a transition to telehealth, it is clear that regardless of the opportunity and innovation that exist, much of the world was not literate or equipped to partake. The factors influencing this are many, but fundamental to all innovation is change. Organizational change requires careful thought and engagement, for as many as 70% of all change programs fail.
In the context of healthcare, patients are central to the process and are key stakeholders. A study conducted by the Harvard Kennedy School’s Center for Public Leadership found that there are eight key factors that contribute to successful organizational change:
1
Create a sense of urgency around adopting telehealth
If you want to help bring about change, you need to be bold and communicate the importance of taking action now. And there certainly is an opportunity right now to do that—as a highly virulent, potentially lethal virus, which can be spread by respiratory droplets from an infected individual, continues to infect people. Heightening organizational awareness is required, but also heightened awareness among your patients. Help generate and focus that sense of urgency, and remember that this should always be inspired and reiterated from those in leadership positions.
The author of the work on organization change points out that if you want your organization to succeed, you need to create a sense of urgency around opportunities that are both strategically rational, and emotionally exciting. This will help to keep all stakeholders motivated and focused on the company’s goals—whether that be by ridding an organization of complacency, maintaining the sense of urgency, or both. In the early days of implementing something new, or undergoing any change in practices or processes, the forces of resistance to such change are strongest. It is important that the leader driving the change, both maintains a sense of urgency and banishes any complacency that may creep in, similar to approaches one might take in helping a patient to successfully implement changes to their lifestyle which impact upon their medical condition. If the urologist is complacent in their work, and in inspiring and motivating change, so too will their patients be, and often so too are their staff.
2
Develop a guiding coalition or dream team for the implementation of telehealth to your practice
While this is the second point, developing a guiding coalition is to the process of change management, what an intact and functional central and peripheral nervous system is to urinary continence. It should consist of members from across your practice or institution, so that check in staff through to medical assistants and nurses are represented, and if it is a larger organization, ensure that all levels of hierarchy are represented. Ideally the guiding coalition will represent each of the functions and skillsets required, and should contain a few outstanding leaders and managers, as well as those who can be trusted to be advocates of the change process. It should be made clear that all members of this guiding coalition are equal, as internal hierarchy can often slow the transfer of information. As a word of advice, do not be dismayed if at first the dynamics of your guiding coalition are uncomfortable, trust that as you lead your group through the process that most members will revel given this opportunity, and many will surpass your expectations.
3
Define the vision and develop change initiatives to capitalize on adopting telehealth
Be strategic in your implementation. Take the time to design and define a strategy what can be executed quickly and with enough energy to make the vision a reality. It is important that the vision is something everyone on your assembled dream team can articulate and feels invested in, one that they can communicate and see a clear path toward, so that everyone can see the path to success and understands it is achievable.
For example, if the vision was a urology practice with the capabilities to offer every practical outpatient service currently possible, taking the time to segment the steps toward a practice that can offer those services to everyone is sensible. Such a process might start with offering follow-up visits to established patients who have been identified as being more technologically literate by a preliminary survey of your practice. Then progressing to offering the same service to gradually more and more cohorts of your practice, who perhaps are less comfortable with technology. By this juncture though, your own staff will have gained confidence in the system from using it with patients who are more comfortable. Then step by step, you can expand the scope of services to a greater proportion of your practice, but make sure you don’t forget step 1—maintain the sense of urgency and don’t allow for patients to be excluded from the benefits of telehealth. Always remember, that if you help people not just see a difference, but feel like they are making a difference, you can help provide them, both staff and patients alike, with a greater meaning and purpose, and great things can happen.
4
Engage key stakeholders and “enlist a volunteer army”
A clear, ambitious vision and strategy, communicated effectively by your “dream team” who believe in it, will motivate people to get on board without the cynicism that often greets messages from management. If done right, with creativity and passion, this can become a self-sustaining movement that attracts employees who buy into the ambition, and feel a sense of urgency. Your initial team who set out to guide this mission forward will recruit an army of those who want to contribute to the vision, rather than those who feel they have to. While you build momentum among staff and patients, remember that greater traction and momentum will build. As patients report more positive experiences to staff, and as staff relay that enthusiasm to coworkers and other patients, the progress and sense of fully realizing the benefits of telehealth will feel more and more within reach, and people want to be part of a success. Remember to recognize the efforts of those who are already working toward the vision, keep engaging them and reenergizing them, and they will succeed.
5
Remove barriers and empower all stakeholders
As you, your team, and the larger enlisted volunteer army make progress, barriers and speed bumps will become apparent. Routines that may have been required for in-person care, or simply survived for no apparent good reason, may prevent or delay the adoption of telehealth in your practice. Everybody should be on the watch out for phrases like—“we tried that before, and it didn’t work”, and “that’s not how it’s done here,” or “they’re just not able,” which are often accepted as answers, and rarely are, but these are indicators of institutional barriers. Help patients and staff remove these blocks. Technology can work for everyone, not just the few.
Perhaps, there is an information technology (IT) policy that will not allow each end user to install updates to the video conferencing application in use in your practice, or there are firewall settings that don’t allow certain connected devices to sync properly. Or maybe some of your patients don’t connect on time or have problems connecting, which makes them late for their appointment time. You already have the key components with your team and volunteer army to help find out why, and figuring out how to remove this barrier. Provide them the tools and authority to solve this problem, even if this means changing how you do things.
6
Generate and celebrate short-term wins
Big or small, anything that helps move you and your practice toward implementing telehealth, is a win. It can be actions taken, lessons learned, processes improved, or the installation of some new devices. Celebrate these wins, not just with staff, but with every patient. These wins can provide confirmation that the decisions and actions are actually succeeding and that your team and army are succeeding. Great wins to celebrate include unambiguous, tangible results, which are directly related to implementing telehealth—such as installing webcams on the relevant workstations, completing your trial run of a telehealth visit, completing your first telehealth consult, and eventually completing your first hybrid clinic, with in person and televisits.
If you can’t see the wins, this is in itself valuable feedback that something is awry. A committed team guiding the implementation can quickly adapt to modify the decisions and actions it has taken to implement telehealth in the practice. It is imperative that you generate small-term wins early and consistently to keep the vision on track, and to deliver the service successfully.
7
Consolidate gains and produce more change
Early successes and wins will reinvigorate you, your team, and patients. This can be used to help sustain and build momentum. You, your team, and telehealth will gain credibility as a viable solution for all, after these early wins. Don’t allow complacency to creep back in. Don’t forget each of the steps that brought you here—starting again with urgency, get more people involved, offer services to more patients, and offer more services via telehealth. As you do this, you’ll experience more barriers, which you, your team, and your patients can remove in due course. Help accelerate the vision to completion, and don’t allow the typical cultural tendencies that lead to increasing resistance to arise.
8
Institutionalize this change culture
It’s much the same for managing patients as it is for managing a practice, as it is for managing a large organization; to ensure these new positive behaviors are repeated over the longer term, it is crucial that you define and communicate the connection between those behaviors and the successes experienced. For example, explain to each patient that their urinary symptoms improved because of the lifestyle changes that they successfully made. Or explain to your clinic staff that phone call volume reduced because they posted regular updates to your practice website or social media accounts advertising and reminding patients of your practice hours. Or in the case of your telehealth practice, that by contacting first time telehealth patients in advance to guide them through the process, leads to clinics staying on schedule, and higher patient satisfaction.
This last step is what will help sustain the progress made in the first seven. The old must be replaced by the new, and it is challenging when old ways are often deeply rooted into practice routines and procedures. Your guiding team and your volunteer army must not be a separate faction from the rest of your practice, but they must synchronize with each other, and then merge to become one effective unit with the same mission. Grafting this new unit and new set of practices onto the stem and roots of an older and still effective unit, will become harder if any of the prior 7 steps loses momentum, and key among them is maintaining urgency. Indeed, as regulations ease and people become more comfortable about in-person interactions, and the need to socially distance reduces, one should expect the die-hard fans of the old ways to attempt to discard what has been gained and what is new. In some respects, a change initiative is never complete, but it certainly isn’t until there is incorporation of telehealth into your day-to-day activities.
Implementation strategy
A successful telehealth implementation strategy is one focused not just on clinical practices but primarily focused on patients to enhance the adoption and sustained use of telehealth tools. Successful implementation strategies improve key implementation outcomes including acceptability, adoption, suitability, feasibility, reliability, cost, penetration, and sustainability ( ). The Expert Recommendations for Implementing Change project was a study aiming to refine a published compilation of implementation strategy terms and definitions by systematically gathering input from a variety of stakeholders with expertise in implementation science and clinical practice. They also identified through expert consensus, 73 implementation strategies for clinical innovations, which are a great reference for you and your practice as you move through this process.
Proactive versus reactive technical support for patients
Many are well accustomed to having to contact and access technical support when they have an issue. However, I would propose that when one needs to access technical support for their health, as in a telemedicine consult, they are in no fit state to be left to automated phone trees, and provided a technological barrier rather than a medical solution. Preparing patients for telehealth is therefore of the utmost importance, and it is incumbent upon us all to not only advocate for a better standard of telehealth care for all, but also to help educate patients, improve their telehealth literacy, and reduce the distance between patients and healthcare that maybe inserted by technology.
While it might be tempting to outsource technical support to someone else, a patient’s experience of your practice is their experience of your care. It shouldn’t be the case that patient care and patient experience be outsourced, or offered for tender where only financial cost is considered. The workflow of a telehealth visit is new not only to patients, but also to the practice and its staff, and often the best teachers are those who have just learned that same thing themselves.
It is also important to remember that not every patient will require the same amount of assistance and attention. Some are more technologically literate than others, and perhaps some designed the systems you are using. When clinicians at Johns Hopkins were adopting to telehealth care provision to the masses amidst the COVID-19 pandemic in 2020, they developed a “video visit technical risk score,” which they added to their electronic health record system to identify patients that would require assistance prior to their telehealth visit and added it to display a color-coded column in the schedule template. The score runs on a scale of 0–4, where 0 represents someone who is very likely to have a successful video visit and 4 representing someone with the greatest chance of having an unsuccessful video visit. The group at Johns Hopkins comprised their score based on the following factors:
Two points for not having an active account in MyChart (an online portal for patients to view their electronic health record).
One point for not having completed an electronic check in process in the seven days prior to the visit.
One point for not having had a prior video visit in the past 3 months.
Or
One point for having had a telephone visit in the past 3 months and no video visit.
These are simple objective criteria which can be automatically calculated from the electronic medical record, and while there are others that may also predict the success of the subsequent telehealth encounter, these are relatively simple to institute.
The Hopkins group employed central IT support, and their frontline clinical and front desk staff, to proactively reach out to patients in high-risk groups, who would most likely need assistance, and started 7 days prior to the scheduled visit. In their instance, they began by sending an automated text message to patients (automated text messaging systems are described in Chapter 6 ). They initially sent further reminders three days prior and the day prior to each patient’s visit, and only to those that had previously consented to receiving communication via text message. In their pilot study, only 2% of patients (7/384) returned a call to the support team for assistance. In the next phase of their work, they offered a text message or a phone call the day before the scheduled appointment. Using this method, they were able to reach 45% (44/98) of patients the day prior to the scheduled telehealth visit. Using their work, it would suggest that those high risk for an unsuccessful video visit be scheduled so that extra time is provided to setup their video visit on the day. Alternatively, opportunistic interventions to improve their ability to access telehealth should be taken when possible, if they have an in-person encounter for any reason, the opportunity could be taken to help them prepare for a future visit, and a small refresher right before the televisit may be sufficient to ensure a satisfactory and successful telehealth visit is achieved ( ).
Engage patients with telemedicine
Helping patients get ready for visits is critically important ( Fig. 5.1 ). Much like any other first impression, a patients’ first interaction and impression with your telehealth service matters. Invest the time into ensuring patients are ready for their visit, especially their first telehealth visit.
