Ensuring Telehealth Implementation Doesn’t Exacerbate Clinician Burnout

January 17, 2023 - Like many clinicians, Eve Cunningham, MD, has experienced burnout, though she didn't recognize it until years later.

"I mean, you get to a point where you just hit the ceiling, where you just can't take anymore," she said in a phone interview. "As a clinician in your busy life, you're managing people; you're taking care of people. There's an emotional aspect to that. You are also having to make lots of decisions that make an impact on people's lives. You obviously never want to make a mistake or do the wrong thing."

Of course, these symptoms of burnout are not unique to Cunningham, an obstetrician-gynecologist by training and the interim chief executive of telehealth at Providence Health and Services.

Survey after survey has shown that burnout among US healthcare workers is on the rise, particularly amid the ongoing COVID-19 pandemic. Data published in September shows that 63 percent of physicians had at least one manifestation of burnout in 2021, compared with 38 percent in 2020.

As healthcare organizations implement strategies to mitigate these rising levels of burnout, some physician leaders that spoke with mHealthIntelligence believe telehealth can help. Telehealth can support efforts to mitigate burnout by providing clinicians with flexibility in how they work and enabling them to widen access to care, which can ultimately help them do their jobs better.

But, on the flip side, telehealth use can also increase clinician burnout, with at least one study showing that physicians who spent more of their clinical time on telehealth engaged in higher levels of EHR-based after-hours work compared to those who used telehealth less. To ensure that telehealth use is not inadvertently worsening burnout, organizations must address telehealth workflow challenges early in the deployment process. 

HOW TELEHEALTH IMPLEMENTATION ALLEVIATES BURNOUT

Cunningham, who is also chief medical officer of strategic partnerships at Providence, said that telehealth has helped curb burnout at the health system in various ways.

Primarily, the implementation of telehealth enabled Providence to cover a broader population of patients with a smaller workforce without stretching its staff to a breaking point. For instance, the health system has a telestroke service through which three neurologists are available for consultations at night for 92 hospitals.

"Those 92 hospitals would never be able to find 92 different neurologists that could cover on any given night," she said. "So, we're able to reach all of these hospitals that maybe don't have the volume to support a specialist onsite. We're able to stretch that specialist support across multiple locations — it helps those caregivers and those providers that are onsite in those facilities."

Similarly, the health system has telepsychiatry and telehospitalist services, wherein a handful of clinicians help provide coverage at hospitals across the state. 

"The people who are onsite — admitting patients, having to be face-to-face with patients — they can really focus on doing what they need to do in onsite care because we're offloading the things that can be done virtually to our virtual teams," Cunningham said.

Further, telehealth provides clinicians with flexibility, helping them connect with patients and intervene sooner, said Steven Shook, MD, strategic lead for virtual health at the Cleveland Clinic.

Conducting visits from their homes can help clinicians do their work effectively while mitigating burdens associated with coming into the clinic.

"We hear from providers that [they like having] that option to potentially do some of their work from home, or even if at the last minute there's a giant snowstorm… You can still see those patients while you're waiting to have your driveway plowed out," he said.

Shook believes that this work flexibility improves provider satisfaction by allowing clinicians to be there for their patients, intervene as needed, and improve outcomes. Not only that, but the flexibility of work-from-home can keep experienced clinicians in the workforce longer.

Along with enhancing flexibility, telehealth can help reduce the "non-value-added time" physicians spend with patients as well as patient no-shows, according to recent research.

"Non-value-added care contributes to physicians feeling rushed and stressed, degrading both the patient and physician experience," said Carrie Nelson, MD, chief medical officer at Amwell, in an email. "For instance, a routine follow-up appointment for a patient with high blood pressure typically includes a blood pressure check and an examination. The examination in this scenario rarely adds anything to the medical decision-making process but is done because 'we've always done it that way.'"

When non-value-added care, like the exam in the above scenario, is cut, it can allow clinicians to focus their time and energy on more useful care services.

Telehealth also helps physicians gain valuable insights into their patients' lives, further enabling them to fine-tune the care they provide.

"If [during a video visit providers see] fast food wrappers are lying around, or there's yelling in the background, different types of questions may surface, versus those that might occur in the sterile environment of the brick-and-mortar exam room," Nelson added.

HOW TELEHEALTH DEPLOYMENT WORSENS BURNOUT

As telehealth becomes increasingly integrated into care delivery, concerns arise about its potentially negative impact on clinician workflows and the risk of fueling burnout.

"Telehealth virtual care has led to increased patient engagement for some patients… [but] there has not been an increase in the support team to handle that increased flow," said Lee Schwamm, MD, vice president of digital patient experience at Mass General Brigham, in a phone interview.

In particular, the increase in patient flow has led to additional EHR work, which is rife with usability issues that exacerbate feelings of burnout.

"One of the biggest contributors to burnout is this sense that the work is never done," he said. "I think we, as health systems and health providers, need to hold EHR companies accountable for this. They need to figure out better ways to process message transactions, filter them in different ways, flag them, automate some of the replies."

Additionally, the rapid deployment of telehealth during the pandemic resulted in a fragmented clinical environment. In many cases, virtual care has not been effectively integrated into the overarching clinical workflow.

According to Schwamm, the telehealth experience at some healthcare facilities is simply a replica of an in-person visit, with Zoom subbing in for a face-to-face evaluation. The work needed to sustain a virtual care environment — like continuity planning, documentation management, and integrating IT systems — remains.

Providence's Cunningham similarly noted that amid the widespread adoption of telehealth early during the pandemic, there was no workflow optimization.

"Imperfect workflows and imperfect routing and processing of information, whether it's messaging or connecting different technologies, can create a significant amount of work for clinicians, for patients, for caregivers," she said.

Not only that, but as patients became increasingly familiar with technology during the pandemic, they grew more comfortable with virtual care options, including asynchronous messaging via patient portals, creating even more work for clinicians.

This added work, which Cunningham referred to as "pajama time work," can make clinicians feel like there are no guardrails to protect their free time.

And that free time is essential, as clinicians need time away from work to avoid burnout.

"It's so critical for workers to be able to have time to unplug and get the rest they need and recharge so they can come back and be here for our patients," Cleveland Clinic's Shook noted.

REDUCING BURNOUT RELATED TO TELEHEALTH IMPLEMENTATION 

As healthcare providers implement and expand telehealth programs, they must be wary of unintentionally adding to clinician burnout.

As described above, workflow challenges related to telehealth are significant drivers of burnout. So, provider organizations should first focus their efforts on mitigating telehealth workflow issues.

One strategy to ensure seamless workflows is automating tasks, such as adding transcription services to reduce the documentation burden, Amwell's Nelson said.

"Similarly, we must find ways to automate other mundane tasks such as the ordering of vaccines and routine screenings," she added. "Much of this can be predicted and automated, based upon a patient's age and medical history."

This speaks to a larger, needed shift in providers' perceptions of telehealth. Telehealth strategy does not mean only enabling video conferencing but also incorporating a wide array of remote care capabilities, including asynchronous telehealth. And measuring clinician experience while implementing those services is crucial, Nelson noted.

Thus, bringing clinicians into the conversation early and often is critical to mitigating workflow issues and ensuring that telehealth implementation does not add to burnout.

According to Providence's Cunningham, these conversations should get into the minute details of clinician workflows and provide space for clinicians to offer feedback before the telehealth tool is deployed.

"It's a little bit of a tedious process," she said. "I think it's sometimes annoying to some of the tech folks. Like, 'really? Do you really want to go this nitty-gritty?' But, it's like, yeah. Because I'm not bringing anything to my docs unless I know it works, and I can stand by it, and they've bought into it."

Schwamm echoed Cunningham, stating that successful telehealth implementation requires the involvement of frontline staff, including the practice assistants, the medical assistants, the front desk schedulers, the physicians, and the nurses, as they know where the workflow bottlenecks are and how virtual care can exacerbate or mitigate those issues.

Further, providers must understand that telehealth is not a panacea and may only be suitable for some types of care. Cleveland Clinic's Shook noted that the virtual care component in some specialties, such as behavioral healthcare, may be far larger than in others. Within some surgical sub-specialties, for example, in-person care will remain necessary.

Thus, Cleveland Clinic aims to help patients find the right care modality for their clinical needs while also creating support systems to help clinicians facilitate virtual access without having to be on-call 24/7, he added.

Even with the challenges that resulted from the rapid adoption of telehealth during the pandemic, the care modality has remained popular among clinicians.

"The proof that this type of care is here to stay and that it's something that our providers enjoy doing is that we still see 78 percent or more of our providers delivering this care," said Shook.

"And that's from a base[line] of 15 percent [pre-pandemic]. It really tells me that the vast majority of providers find this useful. They find it valuable for their patients, and they enjoy doing it."

This indicates that the pros of offering telehealth services outweigh the cons for clinicians. But ensuring that virtual care operations ease workflow issues rather than worsen them will be essential for the long-term success of telehealth programs.

"Technology is not the problem in these situations; it's governance and processes," Schwamm said. "That's where I would start."