How Providers Can Optimize Telehealth Workflows and Improve Experience

March 21, 2022 - The COVID-19 pandemic is directly responsible for the dramatic rise of telehealth. But as providers quickly established new or expanded existing virtual care programs, they may not have addressed certain workflow hurdles and human factors challenges that could result in poor patient outcomes and provider burnout.

That's according to ECRI, an independent nonprofit focused on improving the quality of care, which listed this issue as one of its top 10 health tech hazards for 2022.

These workflow and human factors issues can manifest in different forms, including device usability problems and excessive data volumes.

"There are providers who are now feeling the strain because of these rapidly implemented [telehealth] programs," said Priyanka Shah, senior project officer at ECRI, in a phone interview. "These potentially can lead to poor outcomes, not just for the patients, but also for the providers."

On the patient end, inefficient workflows could take the form of misdiagnoses, while on the provider end, it could result in cognitive overload and clinician burnout, she added.

But steps can be taken to prevent these poor outcomes, including creating a workflow that does not overwhelm providers and ensuring patients have the support they need before, during, and after a virtual visit.

Workflow and human factors issues impacting virtual care

The rapid expansion of telehealth services did not leave providers much time to set up intuitive and standards-based workflows for virtual visits, said Lee Schwamm, MD, vice president of virtual care at Mass General Brigham in Boston.

In a virtual care world, provider responsibility in ensuring visit attendance grows. With in-person care, the onus is on the patient to find and travel to the clinic. But with telehealth, it becomes the provider's responsibility to ensure that the patient can navigate the technology and participate in the appointment.

"You have to spend a lot of time training patients and supporting patients in access," Schwamm said in a phone interview.

Not only that, but telehealth workflows can add a layer of inefficiency to certain parts of the visit, like post-appointment protocols. When care is delivered in-person, patients must checkout after their appointment. This is where several processes occur, like paying the copay, scheduling a follow-up visit, and getting a referral.

"We compress all of those into one physical space so that you get to do all of those at once, and when you leave at the end of your appointment, you have prescriptions printed out if you need them, you have a referral already arranged with another doctor," Schwamm said. "But now we have to do all that asynchronously."

Martin Doerfler, MD, senior vice president of clinical strategy and development at New York City-based Northwell Health, echoed Schwamm.

"[With telehealth], we hang up, and a whole new process has to occur to connect the patient to all of those adjunctive elements that make up an office visit," he said in a phone interview. "All of those are potential breakpoints to lead to an unsatisfactory outcome in terms of the care of the individual."

Setting up an efficient telehealth workflow in any given clinic is a challenge that magnifies across large systems.

"If you look at an organization like ours…we employ about 4,500 individual physicians," Doerfler said. "And those 4,500 individual physicians will probably have 2,500 individual workflows. So, I can't just go out and say, connect A to B, to C, to D like I can in terms of plugging in a router into the wall."

Then there is the issue of cognitive overload among physicians. Telehealth results in more documentation and coordination for physicians, and that can require the use of new software, Shah said.

"We were on so many calls with providers," she said. "Wherein the clear message was, 'Hey, we have so much technology at hand, but this is on top of our existing workload.'"

Also, some of these technologies are just not set up for a virtual environment, Schwamm added. For example, tools built for patient registration, like confirming patient identity, don't necessarily transfer well to a virtual encounter, where patients may not turn on their cameras.

In addition to workflow issues, there are several human factors shortcomings on the patient end that can impact care, including device usability.

Telehealth and remote care plans often require patients to use new types of technology they may not be familiar with.

"We are deploying these remote patient monitoring kits to these patients with the intent of delivering care, but it's not really meeting their needs," Shah said, "The patients [may not] know how to use some of the equipment. So how do you, at that point in time, ensure that you have quality data for the provider to then make a care decision on?"

Along with technology use challenges, lack of privacy in patients' homes can hamper care.

The doctor's office is always private, but a patient may not have a room to themselves for a medical visit at home. As a result, they may not be able to speak openly about their condition or treatment plans, Doerfler said.

Mitigating the challenges

The above hurdles are not insurmountable, but they require providers to think through solutions to ensure efficiency, ease of use, and accessibility.

One key human factors consideration is appropriate patient selection, Shah said. All patients are not going to be good candidates for telehealth. So, providers must first understand their patient's clinical and cognitive needs and the socioeconomic barriers they may face, like lack of broadband access or language needs.

Schwamm suggests providers put themselves in patients' shoes when establishing virtual care journeys.

"There's no substitute for that," he said. "You have to think like a patient and just imagine, 'Okay, how do I start? How do I get notified of an appointment? What if I don't have the portal?'"

When setting up its virtual care service, Mass General Brigham was careful not to make assumptions about a patient's technology capabilities or language needs. The health system is rolling out a single video interpreter service for video visits and at the bedside.

"With one click…that brings an interpreter on in less than 30 seconds, in 40 video languages and 200 audio languages," Schwamm said.

Standardization is another critical challenge for setting up efficient telehealth workflows. At Northwell Health, a telehealth implementation team goes to the hospitals, clinics, and practices within the system to do an initial design of the primary workflow.

"There's an enormous amount of work necessary to create a standard procedure, to the extent that you can," Doerfler said. "And then [we] go back and customize those standard procedures for the nuances of individual practices."

Northwell leaders also realized that, in addition to patients, clinicians needed training on the devices typically used for telehealth and remote care. The health system created a team that acted as standardized patients so clinicians could get a sense of the system and fix small things, like their camera's height and audio issues.

"A member of our team was there to say, 'Dr. Doerfler, fix your cameras a little bit like this. And while you're talking, don't be sitting there looking down the whole time, make some eye contact with me,'" Doerfler said.

As organizations work to improve the virtual care experience, they must keep provider comfort in mind.

Conducting virtual visits and completing documentation requirements can be a physical burden on clinicians. Shah suggests implementing a 20-20-20 rule, which means for every 20 minutes of activity, providers look at something for 20 seconds that is 20 feet away.

"It sounds simple enough, but you'd be surprised how many clinicians don't even have time to factor in break time to improve physical discomfort and reduce cognitive overload because they're so backed up with one after the other telehealth consultations that they don't get a chance to do that," she said.

Further, provider organizations must help clinicians manage the increase in documentation due to telehealth, Shah said. Health systems can help their care teams by ensuring they have enough time to complete their documentation tasks or delegate them entirely.

Then there is the issue of cognitive overload that comes from dealing with the excessive amounts of data that telehealth and remote care can provide. This may require the help of a separate team.

"There needs to be a team or a person within the health system who can help identify patterns, and determine what data is going to be most valuable to the clinician's workflow, and what information should really be fed into the EMR," Shah said.

Telehealth is becoming increasingly entrenched in care delivery. Now is the time for providers to fine-tune their processes and ensure all stakeholders can use and benefit from virtual care modalities. But, remaining flexible as they optimize workflows and overcome human factors shortcomings will be essential.

"You have to be creative; you have to be open to new ideas," Schwamm said. "You have to put the tools out there and then let your users guide you and show you where it's working well, where it needs to be improved and let them apply those tools in ways you never expected. So put gates and boundaries around unsafe practice — but within the sphere of safe practice, let your users figure out what works and what doesn't."