Addressing Evolving Patient Concerns Around Telehealth in the COVID-19 Era

Am J Manag Care. 2021;27(1):e1-e3. https://doi.org/10.37765/ajmc.2021.88576

Takeaway Points

Patients may have new needs, concerns, and expectations around technology-mediated health care within the context of coronavirus disease 2019 (COVID-19).

• Some patients may develop a preference for care via telehealth whereas others may have concerns about privacy or about the quality of care they are receiving virtually.
• Clinicians and health care organizations should proactively address patient concerns (eg, about privacy) given that telehealth is likely to remain an option beyond COVID-19.
• It is important to understand how to evaluate the quality of care delivered via telehealth, including its implications for patient-centeredness.

Over the past decade, there has been a push to help patients become activated and engaged, positioning them in the “driver’s seat” of their health care.^1,2 This framework requires greater attention, consideration, and responsiveness to patients’ expectations and their needs, preferences, and values.^3,4 Considering these factors helps health care organizations achieve the goals of the Quadruple Aim, with incentives introduced to further emphasize the need to pursue patient-centered care.^5,6

However, being a patient in a pandemic is different. As the nature of health care delivery evolves—with perhaps one of the most salient changes induced by coronavirus disease 2019 (COVID-19) being a rapid increase in virtual care delivery—the experience of receiving care has also changed. With the move to telehealth modalities, patients have needed to acclimate to new ways of receiving care and communicating with, or “seeing,” their doctors. Elements of this unprecedented shift in care delivery are likely to remain as we move forward; however, the emergence from quarantine into what has been described as the “next normal” will be complex.⁷ Health care organizations and clinicians must develop sustainable approaches to align with shifting patient expectations and concerns. Policy makers must consider the implications of virtual care delivery, including incentives for encouraging high-quality, patient-centered care. Here, we discuss 3 areas that reflect changing patient expectations: (1) preferences for continuing to use telehealth, (2) concerns about the privacy of health information, and (3) uncertain expectations about the quality of virtual care. We then offer patient-centered recommendations for how clinicians, organizations, and policy makers can respond to these challenges and suggest the need to continue to examine the concept of patient-centered care in the telehealth context.

Telehealth Is More Convenient…But Is It Meeting My Needs?

The hallmarks of health care delivery during COVID-19 have included rapid adoption of telehealth modalities, increased use of remote monitoring, expanded access to digital therapies, and more home-based care.^8,9 Although a “digital divide” persists as some patients struggle to access care due to limited computer and/or broadband access, others who received virtual care via these modalities have reacted favorably to telehealth. Looking ahead, some patients will likely question the value of and need for brick-and-mortar office visits.^10,11 For instance, virtual care options can be convenient for patients because they can mitigate the risks associated with COVID-19 and reduce the costs associated with in-person visits, such as childcare, transportation, or time off from work.^12,13

Despite the added convenience that telehealth offers, it will require that clinicians emphasize building and maintaining rapport with patients and that they work toward shared decision-making virtually.¹⁴ For instance, in this context, one decision to be made is whether patient needs can be adequately addressed virtually or whether an in-person visit would be needed. Optimal shared decision-making in this scenario may require that clinicians encourage patients to express their preferences and/or concerns about modes of care delivery; they may potentially need to engage with family caregivers to understand patients’ social circumstances. Clinicians will also need to discuss safety protocols with patients, particularly when in-person visits are strongly preferred or required. In contrast, when virtual care is both appropriate and preferred, clinicians and their organizations need ways to assess patients’ capacity to use telehealth in light of the digital divide.¹⁵ In this assessment, organizations could ask whether patients have access to devices that enable telehealth visits and whether they have adequate digital literacy prior to scheduling an appointment that involves telehealth.¹⁵ Shared decision-making could also include a discussion with patients about referral procedures and policies, as well as encouraging patients to ask their insurance provider about the need for prior approvals and/or referrals for virtual visits.

How Do I Know My Privacy Is Protected?

When patients communicate with clinicians via phone, email, telehealth platforms, or asynchronously via secure messaging, they may worry about how their personal information is collected, used, stored, and shared with clinicians and across networks.^16,17 Given recent breaches involving personal information, patients may be more aware of and concerned about the protection and confidentiality of their information and may expect information about their clinician’s and organization’s data sharing policies and procedures before engaging in telehealth encounters.^18-20

Patients and clinicians have also begun leveraging applications (eg, FaceTime) to use patients’ personal devices (eg, smartphones) for conducting virtual visits.²¹ Patients may now share information from the comfort, convenience, and safety of their homes, or they may be challenged by the need to participate in visits from public establishments such as work settings or cafés.²² Clinicians now have the ability to learn about their patients’ social and environmental contexts. This new information could improve care quality if clinicians are better able to assess health and safety risks, such as fall risks, or challenges with other social determinants of health (SDOH).²³ However, patients may have concerns about involuntarily exposing aspects of their lives (eg, housing situation) to their clinicians or disclosing sensitive information about their clinical conditions or stigmatized diagnoses in front of other household members.²⁴

Clinicians and health care organizations should help prepare patients for upcoming telehealth visits by explaining how their personal health information will be shared with other providers who are comanaging their care and by ensuring that patient consent is obtained before releasing records. Clinicians, who are gatekeepers of personal health information, could explain to patients how an understanding of their environment may support health care decision-making, and they can suggest that patients move to a comfortable area of their home that meets their privacy preferences. Policies will need to be developed to (1) facilitate family caregiver involvement in telehealth visits and (2) govern the use of SDOH data that may be gathered during telehealth visits.

How Can I Trust That I Am Still Getting the Best Care Virtually?

In an opinion piece in the New York Times, Richard Goggin reflected on his experience of going to a cancer center for a part of his treatment during COVID-19 and being told that he should not be at a hospital; he asked, “Do you think my cancer knows that?”²⁵ Similarly, patients may be concerned that their health needs are being compared against COVID-19 and subsequently overlooked by clinicians. Building relationships, expressing empathy for the changes that everyone is working through, and increasing trust between patients and clinicians will be critical to the transition to the next normal. For example, in virtual environments, mistrust may be exacerbated when there are limited opportunities for building trust and rapport between clinicians and patients and, further, if patients do not trust the technology used in the interaction.²⁶ In the context of virtual care delivery, patients will need to trust their clinicians to (1) give sufficient attention to non–COVID-19–related concerns, (2) be honest about the most appropriate mode of care delivery given patient circumstances and needs, and (3) protect their personal health information, including their social and environmental circumstances.²⁷

Indeed, clinicians may face organizational restrictions affecting their ability to see patients without COVID-19 in person, or they may be concerned about putting patients without COVID-19 at risk of infection transmission by allowing them to come to in-person visits. Patients may also compare in-person experiences with their clinician against virtual visits to determine whether and how much they trust the quality of care delivered via virtual means.²⁸ It will be critical to examine what quality means in the telehealth context and how it differs from our extant definitions of quality in traditional clinical encounters (eg, structure, process, outcomes; the 6 dimensions of health care quality—safety, equity, efficiency, effectiveness, timeliness, and patient-centeredness), as well as to evaluate the implications of these differences from the perspectives of both patients and clinicians. For instance, differences in how we measure and evaluate quality could have implications for telehealth payment parity because traditional quality frameworks may not be directly applicable to virtual care delivery.

Clinicians and health care organizations may benefit from performing outreach to invite patients to obtain the care they may need and discuss challenges, concerns, and alternatives with patients who are skeptical of virtual care delivery; this can contribute to building trust with patients. For example, clinicians supporting patients with limited English proficiency may consider reaching out to ensure that they have access to an interpreter and are not forgoing appointments, are not feeling reluctant to disclose their needs due to concerns about communication, and are not relying on family members who are not licensed professionals for interpretation.^29,30 In such cases, health care organizations should provide patients with access to licensed interpreters who follow regulations, for example, by including the interpreter on the video display,³¹ and consider opportunities to connect patients with clinicians who speak other languages. Researchers and organizations should examine how the rapid growth of telehealth has affected access to remote interpretation services, the challenges associated with implementing these services during COVID-19, and whether the quality of in-person interpretation services is different from that of virtual interpretation.

Conclusions

As we look ahead to the next normal, it will be important for clinicians and organizations to ensure that the shift to telehealth does not overlook patients’ needs, values, and preferences. Policy makers should work with health care organizations to advocate for adequate reimbursement rates for virtual visits to further enable clinicians to use telehealth modalities to monitor, manage, and address patients’ health needs. Patients’ expectations are likely to evolve as they acclimate to virtual care delivery options, and how clinicians respond and adapt to these expectations can shape how health care is delivered beyond the current pandemic.

Author Affiliations: Department of Kinesiology and Community Health, University of Illinois at Urbana Champaign (MR), Champaign, IL; CATALYST, Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University (MJD, ASM), Columbus, OH; David D. Reh School of Business, Clarkson University (ALS), Potsdam, NY; Center for Primary Care, Department of Global Health and Social Medicine, Harvard Medical School (ES), Boston, MA; Department of Public Health Policy and Management, New York University School of Global Public Health (AYL), New York, NY; Department of Management and Organizations, New York University Stern School of Business (AYL), New York, NY; Department of Work and Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University (BF), Maastricht, Netherlands; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (AS), Toronto, Ontario; Department of Family and Community Medicine, College of Medicine, The Ohio State University (ASM), Columbus, OH; Division of Health Services Management and Policy, College of Public Health, The Ohio State University (ASM), Columbus, OH; Department of Primary Care and Population Health, Stanford University School of Medicine (SCT), Stanford, CA; Intermountain Healthcare Delivery Institute, Intermountain Healthcare (SCT), Murray, UT.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MR, MJD, ALS, ES, AYL, BF, AS, ASM, SCT); acquisition of data (AS); analysis and interpretation of data (AS); drafting of the manuscript (MR, MJD, ALS, ES, AYL, BF, AS, ASM, SCT); critical revision of the manuscript for important intellectual content (MR, MJD, ALS, ES, AYL, BF, AS, ASM, SCT); administrative, technical, or logistic support (MJD, AYL, BF, ASM); and supervision (ASM).

Address Correspondence to: Minakshi Raj, PhD, MPH, Department of Kinesiology and Community Health, University of Illinois at Urbana Champaign, 1206 S Fourth St, Champaign, IL 61820. Email: mraj@illinois.edu.

REFERENCES

1. Herzlinger RA. Let’s put consumers in charge of health care. Harv Bus Rev. 2002;80(7):44-50, 52-55, 123.

2. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4, pt 1):1005-1026. doi:10.1111/j.1475-6773.2004.00269.x

3. Six domains of health care quality. Agency for Healthcare Research and Quality. November 2018. Accessed July 10, 2020. https://www.ahrq.gov/talkingquality/measures/six-domains.html

4. Deledda G, Moretti F, Rimondini M, Zimmermann C. How patients want their doctor to communicate. a literature review on primary care patients’ perspective. Patient Educ Couns. 2013;90(3):297-306. doi:10.1016/j.pec.2012.05.005

5. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713

6. CAHPS patient experience surveys and guidance. Agency for Healthcare Research and Quality. August 2019. Accessed June 9, 2020. https://www.ahrq.gov/cahps/surveys-guidance/index.html

7. Berwick DM. Choices for the “new normal.” JAMA. 2020;323(21):2125-2126. doi:10.1001/jama.2020.6949

8. Phadke NA, Del Carmen MG, Goldstein SA, et al. Trends in ambulatory electronic consultations during the COVID-19 pandemic. J Gen Intern Med. 2020;35(10):3117-3119. doi:10.1007/s11606-020-05878-z

9. From “wartime” to “peacetime”: five stages for healthcare institutions in the battle
against COVID-19. McKinsey and Company. April 24, 2020. Accessed June 1, 2020.
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/from-wartime-to-peacetime-five-stages-for-healthcare-institutions-in-the-battle-against-covid-19

10. Polinski JM, Barker T, Gagliano N, Sussman A, Brennan TA, Shrank WH. Patients’ satisfaction with and preference for telehealth visits. J Gen Intern Med. 2015;31(3):269-275. doi:10.1007/s11606-015-3489-x

11. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375(2):154-161. doi:10.1056/NEJMra1601705

12. Lyerly MJ, Wu TC, Mullen MT, et al. The effects of telemedicine on racial and ethnic disparities in access to acute stroke care. J Telemed Telecare. 2016;22(2):114-120. doi:10.1177/1357633X15589534

13. Parke DW II. Ophthalmology after coronavirus disease 2019 (COVID-19). JAMA Ophthalmol. 2020;138(6):599-600. doi:10.1001/jamaophthalmol.2020.2004

14. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q. 2001;79(4):613-639, v. doi:10.1111/1468-0009.00223

15. Velasquez D, Mehrotra A. Ensuring the growth of telehealth during COVID-19 does not exacerbate disparities in care. Health Affairs. May 8, 2020. Accessed October 15, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/

16. Walker DM, Johnson T, Ford EW, Huerta TR. Trust me, I’m a doctor: examining changes in how privacy concerns affect patient withholding behavior. J Med Internet Res. 2017;19(1):e2. doi:10.2196/jmir.6296

17. DePuccio MJ, Di Tosto G, Walker DM, McAlearney AS. Patients’ perceptions about medical record privacy and security: implications for withholding of information during the COVID-19 pandemic. J Gen Intern Med. 2020;35(10):3122-3125. doi:10.1007/s11606-020-05998-6

18. Liu V, Musen MA, Chou T. Data breaches of protected health information in the United States. JAMA. 2015;313(14):1471-1473. doi:10.1001/jama.2015.2252

19. Kruse SC, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare. 2018;24(1):4-12. doi:10.1177/1357633X16674087

20. Platt J, Raj M, Büyüktür AG, et al. Willingness to participate in health information networks with diverse data use: evaluating public perspectives. EGEMS (Wash DC). 2019;7(1):33. doi:10.5334/egems.288

21. Barsom EZ, Feenstra TM, Bemelman WA, Bonjer JH, Schijven MP. Coping with COVID-19: scaling up virtual care to standard practice. Nat Med. 2020;26(5):632-634. doi:10.1038/s41591-020-0845-0

22. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26(5):309-313. doi:10.1177/1357633X20916567

23. Lai AY, Yuan CT, Marsteller JA, et al. Patient safety in primary care: conceptual meanings to clinicians, administrators, staff, and patients. J Am Board Fam Med. 2020;33(5):754-764. doi:10.3122/jabfm.2020.05.200042

24. Holstead RG, Robinson AG. Discussing serious news remotely: navigating difficult conversations during a pandemic. JCO Oncol Pract. 2020;16(7):363-368. doi:10.1200/OP.20.00269

25. Goggin R. My cancer doesn’t care about the coronavirus. New York Times. May 17, 2020. Accessed July 15, 2020. https://www.nytimes.com/2020/05/17/opinion/coronavirus-cancer.html

26. Platonova EA. Understanding patient satisfaction, trust, and loyalty to primary care physicians. Med Care Res Rev. 2008;65(6):696-712. doi:10.1177/1077558708322863

27. Kruse CS, Lee K, Watson JB, Lobo LG, Stoppelmoor AG, Oyibo S. Measures of effectiveness, efficiency, and quality of telemedicine in the management of alcohol abuse, addiction, and rehabilitation: systematic review. J Med Internet Res. 2020;22(1):e13252. doi:10.2196/13252

28. Mayer RC, Davis JH, Schoorman FD. An integrative model of organizational trust. Acad Manage Rev. 1995;20(3):709-734. doi:10.2307/258792

29. Nouri S, Khoong EC, Lyles CR, Karliner L. Addressing equity in telemedicine for chronic disease management during the COVID-19 pandemic. NEJM Catalyst: Innovations in Care Delivery. Published online May 4, 2020. doi:10.1056/CAT.20.0123

30. Diamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A systematic review of the impact of patient-physician non-English language concordance on quality of care and outcomes. J Gen Intern Med. 2019;34(8):1591-1606. doi:10.1007/s11606-019-04847-5

31. Electronic Code of Federal Regulations. Accessed October 20, 2020. https://www.ecfr.gov/cgi-bin/ECFR?page=browse