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SDR 12-282 – HSR&D Study

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SDR 12-282
Encouraging Patient-Centered Communication in Clinical Video Telehealth Visits
Howard S. Gordon MD BS
Jesse Brown VA Medical Center, Chicago, IL
Chicago, IL
Funding Period: October 2015 - December 2019

BACKGROUND/RATIONALE:
Clinical video telehealth (CVT) offers the opportunity for more efficient access to high quality primary and specialist care for Veterans. Enthusiasm for CVT is especially high in the VA given geographical separation between many Veterans and their providers at VA Medical Centers. However, because CVT encounters are by nature less personal than in-person visits, communication during CVT visits may be more challenging for both patients and providers resulting in less patient-centered communication. Less personal visits may have less exchange of information, lower satisfaction, less trust, and poorer outcomes. Indeed, research comparing CVT with in-person consultations found that patients in CVT visits were more passive and that CVT interactions were dominated by providers when compared with in-person visits.
This project will leverage prior work from two HSR&D-funded pilot projects to improve provider - patient communication for Veterans with type 2 diabetes mellitus. In a short-term project, SHP-08-182, the investigators conducted focus groups to elicit and understand patients' barriers to communicating with their providers. This qualitative work was used in a subsequent pilot project, PPO-08-402 to develop an educational video to encourage Veterans to use active participatory communication in their visits to providers. This work was successfully completed and the product is a 10-minute video that, in testing, was found to be acceptable and feasible to show to VA patients immediately preceding their medical encounters.

OBJECTIVE(S):
Objectives: The investigators goal in this project is to develop and test a video intervention and to also develop pamphlets for patients and providers to encourage active and positive communication in CVT medical interactions. The investigators goal was developed with and is supported by the project's operational partner the Office of Telehealth Services and is integral to the goal to ensure patient-centered care in new models of care. Patient-centered communication in medical interactions is critical and plays an important, but often overlooked, role in the delivery of health services.
There are two aims. First, the investigators will develop educational interventions to encourage patients and providers to use active communication behaviors during CVT visits. Second, the investigators will conduct a randomized trial of the video and pamphlet (intervention) vs. pamphlet alone (comparison) in a two-arm randomized effectiveness trial. The investigators will evaluate for improvement in visit outcomes including patient and provider measures of patient-centered care and communication, reduction in several common barriers to clinical improvement, and improved medication adherence measures and hemoglobin A1c. In addition, the investigators will assess the mediators and moderators of the relationship of the intervention condition to outcomes.

METHODS:
Methods: The project will have two phases. In the initial phase of the proposed project the investigators will develop the video intervention. Video development will include qualitative interviews with stakeholders and patients regarding CVT barriers and perceived benefits. The investigators will use several existing resources and an expert panel of co-investigators and consultants to bring these elements together and produce the intervention. In phase 2 the investigators will conduct a randomized trial of the intervention, evaluating for improvement in a number of outcomes.

FINDINGS/RESULTS:
We presented initial findings from phase 1 at the annual meeting of the Society of General Internal Medicine in April 2018.

The citation and text for the two abstracts presented, one oral and one poster is provided below.

1. Gordon H, Gopal RK, Bokhour BG, Solanki P, Westmoreland V, Skorohod N. "CVT changes how you work." Provider perspectives on medical care in clinical video telehealth visits. Poster presentation at the 2018 SGIM Annual Meeting, April 13, 2018. Abstract appears in Journal of General Internal Medicine. 33(2) Supplement, S83-84. 2018.

Background: Health care provider-patient communication during clinical video telehealth (CVT) visits may be less patient-centered than communication in face-to-face encounters.
Methods: Providers and staff (N=10) experienced in CVT at one large Veterans Affairs Medical Center participated in semi-structured in-depth 45 to 60-minute telephone interviews. Interviews included questions about participants' perspectives on facilitators and barriers to communicating using CVT technology in comparison to face-to-face visits. Interviews were audio-recorded, and transcribed verbatim. Interviews were coded using a grounded approach; four coders discussed each transcript to establish a coding dictionary. Subsequent transcripts were coded by two coders, and discrepancies were resolved through discussion. Using the constant comparison method fundamental to grounded theory analysis thematic categories were identified in each transcript. Coherence, credibility, and strength of those interpretations were achieved with multidisciplinary triangulation among the full research team.
Results: We identified four themes describing perspectives on how CVT changes the style of providers' work: (1) technological and logistical barriers, (2) patient characteristics that impact CVT visits, (3) providers perceptions and satisfaction, (4) communication differences between face-to-face and CVT visit. Examples from these themes include providers frustration with equipment issues and with communicating with different staff, and different local resources for clinical testing, imaging, and emergency service at different patient locations. Providers noted that some patient characteristics such as hearing difficulty and comfort with technology make CVT visits more challenging. Providers also noted a need to more carefully self-monitor their behavior (e.g. maintain eye contact) and to explain the logistics of the telehealth visit so patients are well oriented. Differences between CVT and face-to-face visits included that providers expressed limited ability to provide written instructions or give demonstrations during the visit, described CVT as "unfamiliar territory" because of an unfamiliarity with patients known only through CVT, and providers indicated challenges completing the physical exam including inconsistent availability of staff to assist with CVT equipment, and losing the senses of touch and smell when remote staff "become the [providers] hands".
Conclusions: Providers in our study revealed that CVT requires them to change several aspects of their interactions and communication with patients as compared to traditional face-to-face visits. Our findings may be used to develop interventional materials to encourage active and positive communication targeted to patients and providers scheduled for CVT encounters. Educational tools that encourage more patient-centered communication during CVT encounters may allow more rapid acceptance of CVT, thereby improving access to healthcare in underserved areas.


2. Gordon H, Gopal RK, Bokhour BG, Skorohod N, Westmoreland V, Solanki P. "I'm not feeling like I'm part of the conversation." Patients' perspectives on communicating in clinical video telehealth visits. Oral presentation at the 2018 SGIM Annual Meeting, April 14, 2018. Abstract appears in: Journal of General Internal Medicine. 33(2) Supplement, S222. 2018.

Background: Clinical Video Telehealth (CVT) offers the opportunity to improve access to healthcare providers in medically underserved areas. However, because CVT encounters are mediated through technology they may result in
unintended consequences related to the patient-provider interaction.
Methods: Twenty-seven patients with type 2 diabetes mellitus and at least one previous telehealth visit experience were interviewed about their perspectives on facilitators and barriers to communication with their provider during their
CVT visit. The semi-structured telephone interviews were 45-60 minutes, and were audio-recorded and transcribed. A coding dictionary was established, with codes derived from the data. All transcripts were coded by two researchers
and the discrepancies were resolved through discussion by four research team members. Using the constant comparison method fundamental to grounded theory analysis, codes and thematic categories were identified in each
transcript. Coherence, credibility, and strength of those interpretations were achieved with triangulation among the multidisciplinary research team.
Results: We identified seven themes related to patients' perspectives on CVT: 1) technological and logistical barriers to CVT; 2) benefits of CVT; 3) medical visit issues; 4) patient's challenges in communication; 6) provider behaviors;
and 7) patients' trust in provider and staff. Patients expressed their satisfaction with CVT because of shorter wait times prior to the visit and shorter travel distances. Patients also described their challenges in effectively communicating
with the provider, concerns pertaining to adequacy of physical examination, and lack of consistency of the providers. Challenges in communication included that patients reported: feeling less involved during the visit, difficulty finding
opportunities to speak, and feeling rushed by the provider. Patients were concerned about the potential for errors in their care related to the use of a combination of CVT staff and technology to complete the physical examination.
Patients reported that establishing a relationship and developing trust with their CVT provider was more difficult compared with face-to-face visits and that staff turnover contributed to this challenge.
Conclusions: Our findings revealed that patients perceived benefits and difficulties with CVT. Patients believed that CVT was efficient and improved access, but CVT visits posed challenges for patients' communication with their
provider when compared with face-to-face visits. Our results can be used to develop communication skills training programs to encourage active and positive communication by patients and providers engaging in CVT visits. Educational tools that encourage more patient-centered communication in CVT visits may allow for more widespread acceptance and utilization of CVT, thereby increasing access to care in rural areas. Additional research should examine how to reduce patient concerns about the physical exam in CVT visits.

IMPACT:
We presented two abstracts at the April 2018 annual meeting of SGIM.

We presented one of these abstracts at VA research day in May 2018.

We discussed our educational tools at a staff meeting of the Office of Connected Care and we are working with OCC on dissemination of the educational tools.

Our educational tools are deliverables that could be used prior to CVT visits to improve communication and could serve as a paradigm for developing communication aids for other medical conditions and other clinical settings.

Our continued work will evaluate whether our educational intervention(s) will help improve communication and will be associated with better visit and intermediate outcomes. Educational tools that encourage more patient-centered communication during CVT encounters may allow more rapid acceptance of CVT, thereby improving access to healthcare and enhancing the operational mission of the project's partner.

PUBLICATIONS:
None at this time.


DRA: Diabetes and Related Disorders
DRE: none
Keywords: Adherence, Diabetes, Outcomes - Patient, Patient-Provider Interaction, Rural, Telemedicine/Telehealth
MeSH Terms: none