Well, unless you’ve been living under a rock, you’ve noticed telehealth became a big deal in 2020. Every healthcare organization, system, and clinic implemented some sort of “virtual care” option for those unable to obtain in-person healthcare services during the height of the covid-19 pandemic. Now, many of these telehealth rollouts checked the box as “minimally viable”, but they lacked some important and necessary pieces to make them sustainable for the long-term.
In fact, when I was consulting for Georgia’s Department of Behavioral Health & Developmental Disabilities, one of my projects involved developing the operational and clinical guidelines for telehealth service delivery across the statewide integrated clinical support services (a Telehealth Roadmap of sorts).
That project, coupled with my consulting work in the private sector highlighted two great struggles that many organizations face when implementing telehealth or virtual service delivery: 1) you need to develop a specific workflow and process for handling virtual service delivery (and it’s notably different than in-person treatment processes) and 2) the impact of poor patient experience is AMPLIFIED when the patient isn’t on-site. If you’re moving to adopt telehealth, you MUST understand how to deliver real, human connections and experiences in that environment, or you’ll end up with poor clinical outcomes, decreased patient engagement, and low patient satisfaction.
Nail Down the Fundamentals
Before diving into the ins-and-outs of delivering outstanding patient experiences using telehealth, we first need to look at the basics: the infrastructure and processes that need to be in place to even begin to offer telehealth or virtual health services.
The first process you need to have nailed down revolves around informed consent. Prior to covid-19, not many providers offered telehealth or virtual health services, so their treatment consent forms lack wording and education for the patient on telehealth and the procedures, information required, etc. So establishing a standardized patient consent form that includes information about what information is stored, how information is gathered, protected, etc., and who has access to that information is critical.
For example, some areas and jurisdictions do not allow the recording of telehealth sessions without explicit informed consent. Some areas have less strict regulations. Any session that is recorded becomes part of the patient’s medical record and must be treated as protected information. Establishing procedures & protocols that both inform patients of their rights and maintain security of the information is critically important.
Another big area, that is fundamental (and critical), is that of information security; not just security of the videoconferencing platform itself, but also of the environments(s) where services are being provided. For example, educating patients about the importance of making sure they are in a safe, secure environment is important to ensure that their privacy is maintained.
This can typically be done by starting every session with a statement similar to “Please be aware that we are communicating on a secure platform and that I (we, if multiple providers) am in a secure & private environment. I cannot, however, guarantee that your environment is secure. In order to maintain your privacy, please make sure that your environment is secure and that no one can overhear information we may discuss during this session.” In my experience, many clinicians don’t stop to think about making sure the patient’s environment is secure. Taking this step does 2 things: 1) establishes a safe/secure environment for service provision and 2) communicates to the patient that the clinician truly cares for and is sensitive to protecting the privacy of the patient. This helps increase compliance, engagement, and satisfaction with services.
In addition to those two critical areas, you must think about your onboarding, scheduling, and communication processes & workflows for delivering virtual services. This may include a special scheduling process to ensure both the patient & provider have the appropriate technology in place, space to complete the session, and a process for a “test run”. The framework I use with my clients involves a 3-step process to implement telehealth: 1) a pre-session briefing 2) the session and 3) post-session (or care) debriefing. Especially if you work in pediatrics, or another practice area where the decision-makers or guardians are not the ones receiving care but coordinating it, a briefing and debriefing session helps ensure that the patient is able to participate in the telehealth session and that there’s a clear line of communication between the clinician and the support system for the patient.
Once you’ve got the fundamentals taken care of, you can move on to structuring your telehealth sessions in a way that maximizes patient experience and engagement.
Doing Telehealth Right
I’ve written about some of the pitfalls experienced by clinicians and patients alike when implementing telehealth here, but as a brief summary, there are a few issues that you need to watch out for when implementing telehealth. Without boring you with all the details, here’s a short list of the potential pitfalls: 1) tech issues, zoom fatigue, interpersonal communication issues, and glitches; 2) negative patient experiences are magnified in a virtual environment; 3) an over reliance on passive treatment techniques. If you want more information on those issues, reach the full article referenced above.
Now, the question still remains: How do you “do telehealth right”? That is the million dollar question. Here’s how I advise clients on this topic. Now this comes from my work establishing telehealth & virtual service delivery standards and operating procedures for Georgia’s Department of Behavioral Health & Developmental Disabilities as well as my work helping private healthcare organizations implement & roll out virtual health service delivery.
It all boils down to this: offering high-value, high-impact services. Like it or not, telehealth is here to stay. Patients expect it now. Healthcare providers and hospital systems are noticing its benefits from a cost & access standpoint. And CMS has established a precedent for telehealth moving forward.
That being said, you can’t simply apply “standard” or in-clinic practices and procedures to the telehealth or virtual service delivery world. The change in delivery method, treatment environment & context, as well as patient & client expectations all dictate that you learn to take your highest value services & treatment techniques and adapt them for the virtual world. Let’s start with client expectations.
Oftentimes, either in-clinic or over the web, your patients may hold many expectations and beliefs about treatment based on this biomedical model. That being said, your goal should be to provide education and communicate in a way that is both empathetic & understanding, but also reframes their expectations about treatment, outcomes, and recovery. This often involves a discussion about the difference between active & passive treatments. The literature shows that true, high-value treatment is based on active treatments (self-management skills, mindfulness, active movement, etc.) provides better long-term clinical outcomes than passive treatments (medications, manual therapy, surgery, etc.) . Especially in the virtual space, where passive treatments can’t easily be delivered or provided, you must reframe patient expectations about the value of active treatments.
Self-management skills and techniques provide better long-term outcomes than passive treatments. I’m not saying there’s anything wrong with passive treatments, especially if used in a way to encourage or facilitate participation in an active treatment. But I am suggesting that the core components of treatment plans should be based on providing patients with the skills, techniques, and strategies to manage their own health and recovery.
This focus achieves 2 goals: 1) it empowers your patient to become the driver of their own health and well-being and 2) it decreases clinician (or medical) dependence. It fundamentally alters the relationship you have with your patients. No longer are you the person that can put their back “into alignment” or “adjust” their neck, or “massage” their sore muscles. Taking a self-care and self-management approach to treatment, you become a guide and trusted resource to your patient, who is now motivated and taking control of their own health. Your patients begin looking at you as a coach or accountability partner, as well as a trusted advisor on matters related to their health (not just the diagnosis that originally brought them to your clinic).
Continuing on with the theme of active vs passive treatment, and delivering high-value care via telehealth, you must consider patient education. The type of education you provide to your patients, especially in the telehealth environment should “facilitate active engagement approaches (targeted exercise therapy, physical activity, and healthy lifestyle habits) and reduce reliance on passive interventions.” . If self-management, active treatment, and the like offer the highest form of value to patients, then you should educate your patients with that type of information. Especially in the telehealth environment, where a patient might not “see the point” of attending if you can’t physically stretch, touch, or feel the area of pain or dysfunction, you must address these expectations through proper education at the outset of assessment & treatment.
Unfortunately, many clients and patients that show up to clinics across the country tend to value short-term relief at the cost of long-term outcomes. This, again, refers to the seemingly universal desire on the part of patients to receive some treatment or intervention. This is likely due to the fact that, at least for the vast majority of the healthcare industry’s existence, clinicians and organizations have reinforced the idea that passive treatments are the standard of care . Simply put: most patients that walk into your clinic expect you to do something for/to them to relieve their pain, take away their symptoms or dysfunction, etc.
That’s one reason why taking an educational, empathic, and encouraging approach to patient care plays a vital role in helping improve outcomes, engagement, and satisfaction scores. You must address a patient’s expectations early, at the beginning. You should use education as a tool to help patients understand that your ultimate goal is to help them overcome whatever limitation, pain, or symptoms they are currently experiencing by giving them the resources, skills, and support necessary to do so on their own. You can certainly use passive treatment modalities as an adjunct to active treatments, self management, and the like. But your patients need to understand that your role in the process is to provide the necessary encouragement, support, and assistance to empower them to take control of their own health and well-being. You’re a coach, a mentor, a guide; not a handyman or Mr. Fix-it.
Ultimately, you need to understand that telehealth & virtual healthcare delivery models are here to stay. The key to diving into that world lies not in the technology, or the interface, or the format —although you should try to get those squared away. The key to implementing telehealth is to remember what your true high-value services are. Your high-value, high-impact services are your ability to encourage, guide, and empower your patients into taking the driver’s seat in their own health and well-being. It lies in your ability to build true, lasting relationships that can be used to support your patients as they make these behavioral changes, and in helping them develop the self-management skills they’ll need to stick with them. Telehealth might limit your ability to physically touch, assess, and interact with your patients, but that constraint forces you to lean into the true value that you, as a clinician can provide.
 Cosio, D., & Lin, E. (2018). Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Global advances in health and medicine, 7, 2164956118768492. https://doi.org/10.1177/2164956118768492
 Caneiro JP, Roos EM, Barton CJ, et al. It is time to move beyond ‘body region silos’ to manage musculoskeletal pain: five actions to change clinical practice. Br J Sports Med. 2020;54(8):438‐439. doi:10.1136/bjsports-2018-100488
Rafael E. Salazar II, MHS, OTR/L (Rafi) is the Principal Owner of Rehab U Practice Solutions and the host of The Better Outcomes Show. He has experience in a variety of rehab settings and has worked in a variety of settings, from orthopedic and musculoskeletal rehabilitation, to academia, and even healthcare consulting. He spent the majority of his clinical experience working at Charlie Norwood VA Medical Center, where he was the lead clinician and clinical education coordinator for the outpatient specialty rehab program. In this role, he treated many veterans with chronic pain and helped to establish an interdisciplinary pain management program. He has worked on projects ranging from patient engagement initiatives to marketing communication campaigns to a multi million dollar project assisting the State of Georgia’s Department of Behavioral Health and Developmental Disabilities transition individuals out of state institutions to community residences & implementation of their telehealth rollout. He also has experience as a core faculty member at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, and he serves on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations deliver uniquely impactful patient experiences by improving service delivery through training & advisement and through courses & training programs. He is also a co-founding member of CRA Learning & owner of ProActive Rehabilitation & Wellness.