Telehealth Best Practices: Alexa B Kimball On How To Best Care For Your Patients When They Are Not Physically In Front Of You
Part of appearing reliable is also anticipating technical obstacles that patients might encounter and working with patients to overcome them. Be prepared to suggest a phone number to call in if video conferencing is not working. If technical problems still persist, get the names of relatives or nearby friends who could assist, and consider developing navigator programs for first-time users.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Alexa Kimball.
Dr. Alexa Kimball, MPH — President and Chief Executive Officer of Harvard Medical Faculty Physicians at BIDMC, Inc., an academic multi-specialty group practice with more than 1,500 Harvard Medical School faculty members at Beth Israel Deaconess Medical Center in Boston, and an additional 450 physicians in Eastern Massachusetts. She is also President of the Beth Israel Deaconess Care Organization (BIDCO) Physician LLC, which maintains a membership of approximately 2,900 physicians. A Professor of Dermatology at Harvard Medical School, Dr. Kimball’s areas of research include psoriasis and hidradenitis suppurativa.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
As long as I can remember, I have been interested in the intersection between science, communication and policy. Unlike many medical students, I had little idea of what being a doctor would be like. I had worked in a laboratory but had barely stepped into a hospital and never shadowed a physician at the time I applied to medical school. But I knew that I liked science and caring for people, so it seemed likely a good path. Luckily, it turned out that I truly thrived in clinical medicine, but also found the opportunity to weave in all the other things that I am interested in: discovery, epidemiology, outcomes and leadership.
Can you share the most interesting story that happened to you since you began your career?
While I am lucky to have encountered much that is interesting in my career, my experience during the recent pandemic of course stands out. I have seen the health care community rise to many astounding challenges, including the Boston Marathon bombing, but the pandemic was truly unique: the complicated and dynamic situation, the severity of the risk and threat to health care professionals and the public, which at the outset was largely unknown, and the speed at which change was required are all unique aspects that I do not believe will ever be duplicated. We needed to shift our entire health care system in a matter of weeks — which we did, to the benefit of patients and caregivers alike.
Some of those changes will be lasting, and will make a marked difference in the availability and accessibility of care. We needed to think creatively to solve problems at hyper speed — for example, calling on the engineers at Harvard to design, 3D print and quickly deliver nasal testing swabs. The development, testing and delivery of vaccines was also an extraordinary achievement. But it was also the smaller things; the words of kindness, the gifts of food and housing for our health care workers, the offers of help. We came together as a community, and the support and appreciation for health care workers was wonderful to witness and experience.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“We cannot solve problems with the same thinking we used to create
them.” — Albert Einstein
Some of my most important insights have come from challenging myself to question conventional wisdom or to link ideas across my activities in research, clinical care and leadership. Sometimes the problems are very familiar but the solutions need to be radically different, and we need to be able to think flexibly, recognize the right use case, and persist in taking new ideas forward. I often say to my leadership team: if we aren’t failing sometimes, we aren’t trying enough things.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
It’s really not just one person: so many have advised, sponsored, inspired or taught me something. I’m always grateful for those moments — you never know what piece of advice, connection you make, or random event, will subtly or dramatically change the direction in which you are heading.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
One advantage of in-person care is that it can be faster and easier to get certain kinds of information. We learn a lot just by watching how patients move, how they interact with us, how they seem overall. We also get important information such as vital signs, blood pressure, heart rate and temperature, etc. We can do a physical exam or an eye test, we can feel lymph nodes and listen to the heart. In some cases, an in-person visit also enables physicians to gather context for that patients’ needs. This is particularly true in my field of dermatology: we often need to look at all of a patient’s moles to tell if one is truly unusual. It’s difficult to do that type of full body examination through a computer camera; and you risk missing something that you would have figured out if you could have seen the person face-to-face. I often encounter meaningful findings when I am examining patients for something else: a melanoma is the most consequential of course, but I have also found a live tick! I was able to remove it and treat the patient for lyme disease in that instance.
That said, with a good set of pictures, I can often use tele-health to help a patient in an urgent situation. And, as you mentioned, being able to help patients who otherwise would not be able to get to the office or be seen in person, is an incredible benefit of tele-health. And often, there are scenarios in which an office visit isn’t necessary, and we can save the patient the time and challenges of getting in to be seen in person.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
Moving patients to the virtual realm can make it more difficult for physicians to establish trust. Even if you’ve done your best to present yourself well over a video call, the technology itself works to undermine a physician’s credibility. There’s a disjunction on these calls between video and sound — the sound is delayed very slightly. This apparent hesitation may suggest to patients that the physician is less competent than they actually are.
Empathy can also be more difficult to convey. Even though patients and physicians can see one another on a video call, there’s a world of information that we normally take in unconsciously in in-person conversations that simply isn’t there over video. We don’t have the evidence of all five senses to help us build an impression of the person we’re talking to. The sound waves of our voices are compressed as they’re being transmitted, affecting in subtle ways the way we perceive tone and intent.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)
At baseline, most patients want to trust their doctors. Five central elements contribute trust, some of which I discussed in a recent Harvard Business Review article: reliability, empathy, logic, competence and technology.
- Be reliable. By reliability, we mean showing up when the patient needs you. This means both having ready access to fit patients into your schedule when they need you, but also being on time for visits. People view timeliness in a different way in the digital world and it’s important in signaling to patients you are there when they need you — that you are reliable. Part of appearing reliable is also anticipating technical obstacles that patients might encounter and working with patients to overcome them. Be prepared to suggest a phone number to call in if video conferencing is not working. If technical problems still persist, get the names of relatives or nearby friends who could assist, and consider developing navigator programs for first-time users.
- Convey empathy. In the clinical setting, appropriate levels of light touch can be incredibly reassuring and have valid therapeutic impact. Given that physical contact is impossible in the virtual world, listening becomes even more important. Use verbal cues like “mm-hmm” to indicate that you’re listening while giving patients plenty of time to finish their thoughts. Mirror the patient’s language to convey empathy and build connection.
- Demonstrate logic. Patients want to know that you remember them, know about them, and are thinking about their problem comprehensively and logically. This is actually sometimes easier to do in virtual visits than during in-person ones. Since both patient and record are on the same computer screen, virtual visits offer an opportunity to look at a patient’s record with them and share your thinking. And with the increasing ability for patients to see your notes, you can use that opportunity to reinforce key points.
- Communicate competence. The background and appearance of the physician matters especially in a virtual setting. It’s harder to establish credibility if you cannot make eye contact and engage because your camera is askew, or your background appears informal or sloppy. Make sure your surroundings look clean and professional, and look directly at the camera while speaking to create the impression that you’re making eye contact. Bright lighting is particularly important since the eye takes in more light than a computer camera.
- Know the Technology: Appearing uncomfortable with the technology required for a tele-health visit will work to undermine a patient’s perception of your overall competence, and thus their trust. Test your tech thoroughly before meeting with patients and be ready to help patients troubleshoot glitches as needed. Doctors should also be conscious of the barriers to access many patients may face when it comes to telehealth. Depending on the patient population you serve, some of your patients may not have strong enough internet connections to enable glitch-free video consultations. Others may not have private space in their homes where they can freely discuss all their symptoms and concerns.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
- Telehealth can lead to better and more consistent care by providing many more touchpoints for patients with chronic conditions, such as diabetes. For example, diabetic patients require continuity of care and often need to see their doctor at least 3 or 4 times a year, in addition to having appointments with other specialists for eye exams and other diabetes complications. This can present obvious challenges for patients: having to take a day off from work, find childcare or just find a way to get to the doctor’s office, which may be far from their home or which may require a ride if they do not have a car. All of these challenges are alleviated with tele-health visits.
- Telehealth also makes keeping appointments much easier, allowing for more frequent visits so that patients have more consistent access to behavioral health coaching, podiatrists, nutritionists, and other essential tenets of diabetes care. Doctors in our practice have found that tele-health visits are especially convenient for elderly patients who may not drive. It also enables us to reach patients in rural areas or different parts of the country/world who may not have access to specialists.
- Lastly, tele-health often makes it easier to involve family members, as you can conference in the family members so that they can hear the same thing at the same time and have the opportunity to ask questions.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
In our practice, meeting our patients’ needs for language support emerged early on as one of our primary tele-health challenges. In a survey of our providers using tele-health last spring, 80% identified including interpreter services during video visits as a crucial feature for improvement.
Interpreters and other forms of language support are indeed just as important for online visits as they are for in-person ones. However, aligning interpreters with the patients who need them can add significant operational, as well as technical, challenges. Despite significant technology challenges, this feature is now a permanent part of our integrated tele-health platform. Our practice group partnered with Beth Israel Deaconess Medical Center (BIDMC) to develop the capability on a new tele-health platform that also integrates tele-health within the organization’s existing EMR, enabling providers to easily schedule and launch visits within established workflows, while simultaneously documenting the visit.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
One area we are working to improve relates to privacy concerns. HIPAA regulations control for confidentiality on the physician’s end of the tele-health environment. But there is no way for us to safeguard privacy on the patient-side of the connection. That generates a wide range of new confidentiality challenges, from difficulties in screening for intimate partner violence to concerns about “Zoom bombing,” visits being recorded, and appointments being tracked. Moreover, when a patient doesn’t feel they are in a safe, private space, they may be less forthcoming in discussing their medical issues. Even speaking in front of a loving spouse or children about the details of medical conditions can be an anxious and uncomfortable situation for some patients. This is a key area that will need more attention and resources in order to take tele-health to the next level.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
Patients can prepare for tele-health visits by troubleshooting their technology so that they don’t inadvertently lose important time with their doctor. Otherwise, the same suggestions we would provide for an in-person visit apply: create an updated list of the medications you are taking, think through the questions you want to ask, know who your PCP is and where your last laboratory work was done. Having relevant information at hand means the physician can spend more time with you and less time chasing down data. If it helps you to remember or to more easily share with your family members, don’t hesitate to take notes during the visit.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
Remote home monitoring holds real promise, but the challenge to date is how to make sense of all the data and present only the highly relevant information to the care team. Taking it one step further — could we start to transmit heart and lung sounds by using some of these virtual realities to position a stethoscope? There are definitely some exciting things to think about.
Is there a part of this future vision that concerns you? Can you explain?
Telehealth can create the misperception — for both patients and clinicians — that doctors are always on call. Add in the physical manifestations of increased screen time, such as eye fatigue and the musculoskeletal impacts of a more sedentary workday, and it’s no surprise that some physicians are reporting increased job stress. We also need to recognize that telemedicine diminishes some aspects of the way we practice which can make us feel less confident. For example, when we are not in the same physical space as our patients, we miss out on physical cues such as how well someone is walking and moving. In addition, communication changes because we can’t rely on traditional cues for comfort/discomfort, when to change topics, when to end the visit.
Another area of concern is related to reimbursement: while regulatory frameworks and provisions for reimbursement have shifted in the wake of COVID-19, these have not yet become permanent. Patients need to join providers in leading efforts to prevent a dialing back of access to this service. Much more needs to be done to ensure that providers can test new platforms and continue to reap the benefits of telemedicine post-pandemic.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
Just as we have started teaching nutrition to elementary school students, I’d love to see us teach more about over-the-counter medicines and self care. There are many helpful products out there, but the ingredients and labeling are confusing and the number of options overwhelming. It’s a form of health literacy, and teaching this like we teach nutrition in schools would be a non-traditional way to achieve it.
How can our readers further follow your work online?
https://www.linkedin.com/in/alexakimball-md-mph/
https://www.ncbi.nlm.nih.gov/myncbi/alexa.kimball.1/bibliography/public/
Thank you so much for the time you spent doing this interview.
