Telehealth Fatigue: Is It Real? What Should Be Done?

Abstract

This commentary article discusses the recent trends and changes in popularity of telehealth usage as well as the most recent efforts to redefine telehealth value and usability. Six strategies to improve the patient experience and increase telehealth acceptance by overcoming simultaneous barriers are presented, which include (1) creating a new healthcare paradigm using telehealth, (2) scheduling the telehealth visit, (3) preparing for the telehealth visit, (4) conducting the telehealth visit, (5) using data and biomarkers, and (6) providing digital equity. With the application of these strategies, we believe that the recent decline in the popularity of telehealth can be reversed.

Introduction

Telehealth, compared with in-person care, offers distinct advantages to patients by allowing access to healthcare at more convenient times, allowing interaction with a greater number of remote professionals without regard for distance, and minimizing exposure to coronavirus disease 2019 (COVID-19). Furthermore, telehealth, compared with in-person care, offers advantages to clinicians by allowing for asynchronous messaging and communication, providing a platform for reviewing data from wearable and digital heath devices, and decreasing the cost of care delivery.

Telehealth for many diseases, including diabetes, grew exponentially at the start of the COVID-19 pandemic, aided by changes in reimbursement models, but its popularity is now waning. Telehealth utilization in 2021 was 38 times higher than pre-pandemic rates, and among 23 medical specialties, endocrinology had the third highest share of telehealth claims. ¹ A 2021 survey conducted by Kaspersky Healthcare showed that 91% of clinicians incorporated telehealth into their practice since the beginning of the pandemic, yet fewer than 21% of them had used telehealth before the pandemic began. ²

Recently, there has been a decrease in telehealth utilization since its peak in 2020. ³ A survey conducted by Rock Health in 2021 showed that a decreasing number of patients preferred telehealth over in-person visits since 2020.^3,4 For the management of type I diabetes, there is also a decrease in the number of telehealth visits following the initial spike in April 2020. ⁵ Similarly, a survey conducted by Fair Health in January 2021 showed that the drop in telehealth usage mirrored the sharp decline in COVID-19 cases. ⁶ They concluded that the decline in telehealth popularity could be the result of decreasing concerns of contracting COVID-19 infection during an in-person visit. Deployment of telehealth happened quickly in 2020 and patients were initially understanding and appreciative of this rapid pivot to allow them to continue to receive care. Partaking of telehealth is now a choice for patients and clinicians, and various benefits in efficiencies for both patients and clinicians have accrued from the widespread use of telehealth. Given the recent waning telehealth’s popularity, we contend that patients and clinicians are currently experiencing telehealth fatigue. The Gartner hype cycle is a graphical presentation of the maturity, adoption, and social application of new technologies and consists of five phases of popularity: (1) a technology trigger at the onset of adoption, (2) a peak of inflated expectation, (3) a trough of disillusionment, (4) a slope of enlightenment, and (5) a plateau of productivity. ⁷ We contend that telehealth is in the third phase, and with proper attention to best practices, this type of healthcare can get past the current state of telehealth fatigue and advance to become an effective and productive form of healthcare delivery.

Six strategies to increase telehealth acceptance, overcome telehealth barriers to improve the patient experience, and advance adoption of telehealth are presented in this article. These strategies include (1) creating a new healthcare paradigm using telehealth, (2) scheduling the telehealth visit, (3) preparing for the telehealth visit, (4) conducting the telehealth visit, (5) using data and biomarkers, and (6) providing digital equity.

Creating a New Healthcare Paradigm Using Telehealth

A key consideration with telehealth is whether it is merely a technologically enabled transposition of an in-person visit for a virtual visit, or whether it represents an opportunity to imagine something entirely different by applying digital health tools for collecting, analyzing, and acting upon sensor-generated data. Telehealth practitioners must address the question, “How can telehealth use the unique and differentiated capabilities of digital health tools without emulating the in-person visit?”. Telehealth can facilitate the connection of multiple decentralized data sources from home and the free-living state (without having to be tests at a central lab or hospital) on a daily basis. Telehealth can leverage algorithms to synthesize those data or apply machine learning to assist patients and their clinicians in decision-making based on denser and longitudinal measurements. Telehealth also means that various types of remote and asynchronous communication can occur, including by way of email, text messaging, shared mobile access to mobile app data, and phone messaging. These alternate modes of communication work well with algorithms for turning data into knowledge and knowledge into decision support systems. For example, data from a smartphone-connectable glucose meter or a software-implemented smartphone for real-time glucose data transmission can be sent to a decision support software-assisted remote server capable of performing comprehensive data analysis. This process can provide prompt feedback to the patient and the health care professional through predefined algorithms recently reported to improve metabolic control. ⁸

Treating diabetes can be stressful for clinicians. Although telehealth care for diabetes allows patients to enjoy easier access to the care team and deliver a variety of digital health data streams requiring interpretation to the care team, these types of increased interactions can potentially become a burden for the care team. ⁹ The increased volume of information exchange highlights the importance of establishing a new workflow for patient management as well as defining clear roles and responsibilities for data organization and interpretation within the care team based on individual skill levels. Telehealth or “digital health” tools can provide a new paradigm for user experiences that are more individualized, convenient, and relevant to patients on a daily basis. ¹⁰ Nevertheless, telehealth will never replace essential components of a face-to-face encounter and should not. Digital health, rather than replacing in-person encounters, expands our capabilities for serving our patients.

Scheduling the Telehealth Visit

An emerging best practice to enhance the telehealth visit experience is scheduling telehealth and in-person clinics in separate blocks. In-person clinics, with various components of parking, check-in, vitals, rooming, and manual uploads of technology, have multiple opportunities for delays, which ripple to subsequent patients. Telehealth clinics, however, have fewer opportunities for delays and tend to run more efficiently. Scheduling in separate blocks also allows clinicians to hold telehealth clinics in alternate locations, such as their office or home, freeing up clinic space. Determining the ratio of telehealth to in-person blocks can be determined by a health system’s information technology (IT) or access teams to understand current patient demand. These blocks can be revised based on wait times and percent of unfilled slots for each modality.

While telehealth is often discussed as an all or nothing approach, many clinicians recommend a hybrid model of care. Clinicians and patients should discuss future plans for visits, including how many visits are recommended per year and what percent might be telehealth versus in-person. A hybrid approach allows more flexibility in how patients interact with other members of a multidisciplinary diabetes team. ¹¹ Visits with certified diabetes care and education specialists (CDCESs), dieticians, and behavioral health specialists may all be amenable to telehealth and should be considered.

Patients and clinicians may have different preferences about telehealth. One barrier to a positive telehealth experience would be if a patient requests telehealth, and the clinician denies this mode of care because of personal preference (and not a medical reason). Clinic staff should be aware of these mismatches around patient and clinician care preference and consider transitioning care to another provider who may be more open to the patient’s preference.

Preparing for the Telehealth Visit

Telehealth, compared with in-person contact, requires clinicians to do more pre-visit work, reviewing previous notes, recent labs, and glucose data prior to joining the virtual room. Individual patient needs should be anticipated and addressed prior to the visit. (Is this their first telehealth visit and do they need assistance logging in? Will they require an interpreter that needs to be arranged?) Technology needs to be checked, and a backup plan should be in place in case of a technology failure.

When clinics were performing high rates of telehealth in spring and summer 2020, new staffing models emerged to improve clinic efficiencies. At this time, fewer patients were coming to clinic in person, so clinic staff were given alternative tasks related to telehealth visits, in an all-hands-on-deck approach. Tasks included the following: providing information about joining the video call the day of the visit, technology troubleshooting, e-check-in, and medication reconciliation. For people with diabetes, additional pre-visit discussion occurred around how to share glucose data with the clinician. Now that telehealth visits have decreased in frequency and are starting to plateau, ³ clinic staff are back to performing in-person tasks such as patient check-in and rooming. For those professionals still conducting some clinics as telehealth, support for these clinics varies.

For patients and providers to maintain high rates of satisfaction and sufficient quality of care with telehealth, clinics should reflect on early pandemic workflows and make efforts to support both in-person and telehealth clinics. Examples of pre-visit tasks to be completed by a medical assistant or nurse include medication reconciliation, plan for glucose data, confirmation of receipt of pre-clinic laboratory results, request for at-home vitals, and agenda setting. This can be done the day prior or on the day of the telehealth visit. ¹² During the visit, clinicians can use the “share screen” function which is an interactive way to share data with the patient (such as a pump download or an ambulatory glucose profile) and can provide a similar level of engagement as an in-person visit.

Conducting the Telehealth Visit

The clinician should start the visit on time, from a private space with no distractions, look directly at the camera (rather than the patient), and speak slowly and clearly. ¹³ If there is nose in the background, then use of headphones with a noise-canceling microphone can improve communication. Front lighting (rather than rear lighting that makes the picture look dark) and good eye contact will help communication. It is often helpful to include a caregiver or support person at the visit to later review the visit’s plans with the patient. Plans for follow-up (and how this will be scheduled), future labs, and how to contact the clinic if interim issues arise should all be addressed.

Using Data and Biomarkers

Digital health tools can measure biomarkers and do not necessarily require in-person review of data. Data from such devices can be analyzed by patients and clinicians remotely by way of telehealth. Thus, telehealth is a way to study and disseminate information collected as part of the new precision medicine paradigm for diabetes management. Digital health tools can collect metabolic, physiological, behavioral, and environmental data to enable a precision medicine approach to diabetes and other diseases. Ultimately, a precision medicine approach to identifying treatments for the hyperglycemia of diabetes will require three steps. The first step will be for geneticists to identify robust and reliable genetic predictors of response through genetic screening and omics studies. The second step will be to identify and measure metabolic and physiological biomarkers which can reflect targets of pharmacotherapy (eg, glycemic burden stratified by way of continuous glucose monitoring and glycated protein measurements, beta cell function, insulin sensitivity, body mass index, liver fat, metabolite profile, cardiac function) because these biomarkers will reflect likely responses to selected diabetes drugs. The third step will be to demonstrate that treatments selected on the basis of genetic and metabolic or physiological biomarkers lead to improved outcomes. ¹⁴ Results of biomarker studies can be discussed via telehealth and algorithms can be prescribed remotely by way of telehealth programs. The linkage between use of digital health tools and remote care will make precision medicine paradigm highly suitable for telehealth, and if advanced robust treatment algorithms can be developed, then the appeal of telehealth will be enhanced.

Providing Digital Equity

People with diabetes receiving care at a federally qualified health center, versus diabetes centers in the United States, are more likely to receive telehealth care by audio versus video platform (eg, phone vs zoom).^5,15 Patients have reported feeling telehealth care was as effective or more effective than in-person care, and they stated they would like to have telehealth as an option for some or all of their future visits. ¹⁶

Intentional focus and person-centered design are needed to move toward equity for people living with diabetes. Access to data and telehealth may be key to addressing disparities in care and outcomes. Individuals from marginalized and historically excluded communities encounter barriers to care that are not experienced by privileged groups. When choosing to attend a medical appointment, minoritized groups must often consider the loss of hourly wages, child and family member care, and transportation barriers, which do not often impact those from higher socioeconomic groups. Digital connectivity has been called the sixth vital sign to support personalized clinical decisions based on automatically collected data. ¹⁷ The ability for patients of all socioeconomic statuses, races, ethnicities, and identities to have access to diabetes-specific technology (eg, continuous glucose monitoring, data tracking, telehealth) may be one way to decrease burden on people with diabetes and lessen the disparity gap. People with diabetes could share data with their clinicians who could then reach back asynchronously via a telehealth communication method.

Clinicians should use communication methods that are accessible to people from disadvantaged backgrounds (eg, text vs email, asynchronous communication vs needing a synchronous connection). Patients could receive care when they need it instead of when the healthcare community schedules it. Importantly, people living with diabetes should guide healthcare professionals on what is critical and notable to them versus the standard medical approach of focusing on what is important to the healthcare system. More person-centered care with the support of technology and telehealth could truly transform diabetes care for all people with diabetes, especially marginalized and historically excluded communities.

Conclusion

Telehealth is an established method of healthcare delivery. Telehealth, compared with in-person visits, offers advantages to both patients and clinicians. The appeal of and demand for telehealth were greatest at the beginning of the COVID-19 pandemic but have since declined. The world developed a new attitude toward remote commerce and services during the pandemic, and tools for conducting remote data collection, data analysis, and communication have recently become much more widely used thanks to the digital revolution. In the future, the type of telehealth experience will significantly affect the amount of uptake of telehealth care and drive preferences from in-person to telehealth visits.

Telehealth fatigue can be overcome. Six strategies can be applied to maximize the appeal of telehealth and increase utilization of this type of care. These strategies include (1) creating a new healthcare paradigm using telehealth, (2) scheduling the telehealth visit, (3) preparing for the telehealth visit, (4) conducting the telehealth visit, (5) using data and biomarkers, and (6) providing digital equity. Increased appeal will lead to increased telehealth use, with the potential for improved outcomes and an improved patient experience.