Health systems seek out patient, physician feedback to improve telehealth

As Jefferson Health in Philadelphia saw its telehealth platform volumes skyrocket during the first few months of COVID-19, technical glitches started occurring.

In mid-March, complaints from providers and patients about technical problems kept cropping up. They cited video and audio issues as visits using Jefferson’s virtual platform rose by up to fiftyfold.

To understand more about the technical challenges, Jefferson quickly instituted a survey that pops up immediately after visits for both the patient and the provider, asking about the devices being used and details on the audio and visual problems. The health system has since acted on many of those concerns, working with its technology partner to fix back-end problems causing glitches.

The changes have made for a much better platform, said Dr. Judd Hollander, who leads Jefferson Health’s telehealth program called Jeff-
Connect.

Patients and providers “drove us to dramatically improve the product,” Hollander said.

Jefferson’s experience echoes that of other health systems responding to the growth of telehealth services. When COVID-19 emergency orders went into effect in mid-March, some providers had to quickly create telehealth platforms or build out existing ones to meet the heightened demand. Problems quickly came to the forefront with the technology and how it fit into the patient-care workflow.

Health systems that see telehealth fitting into their future long-term are now working through those challenges, and are seeing that the key to finding solutions is hearing from patients and staff directly.

“We are seeing health systems taking actions now to address these issues,” said Brian Kalis, managing director of digital health at Accenture. “Forced adoption really accelerated and brought to light a number of the challenges that existed before.”

The pressure is on for health systems to create digital experiences patients will enjoy or risk losing out on revenue. In the digital age, consumers have high expectations of what these platforms should be like. “Systems are no longer just competing with other health systems in their region, they are competing with the experiences people have in their daily lives from other brands—that is the bar,” Kalis said. “When those experiences are cumbersome, that can lead to choosing one provider over another … and in the most extreme case, even switching providers.”

Telehealth’s increased popularity has prompted Stanford Health Care to totally rethink how it is assessing patients’ experience with the platform. The California system now does about 62,000 telehealth visits a month, up from about a 1,000 a month before COVID-19.

Now that volumes have stabilized and are staying strong, Alpa Vyas, vice president for patient experience at Stanford, said leadership saw an opportunity to reflect on lessons learned during the growth period and ways to improve patient experience.

Stanford asked more than 50 patients and some physicians who have experienced video visits for feedback on what didn’t work and what types of questions should be included on a telehealth survey. The result is a new survey that is more flexible and specific to the Stanford experience, said Mysti Smith-Bentley, executive director for service excellence at Stanford.

The previous survey was static and limited how much valuable intel it was gathering, she said, because questions weren’t changed frequently and weren’t specific to Stanford.

The new survey, launched at the end of June, asks about pre-visit scheduling and instructions; connecting to the visit; wait times; visual and audio communication with the provider; and post-visit planning. There is also a section for patients to provide comments about the visit overall and the provider.

Smith-Bentley said Stanford plans to remove items when it appears an issue has been addressed and then add new items with more recent concerns.

“Even now if we see that 95% to 99% of patients tell us something isn’t a problem, we should ask something that is more relevant so we can continue to improve,” she said.

The survey’s response rate is about 25%, which is higher than for Stanford’s inpatient surveys. The survey shows up in the patient portal immediately after the physician ends the visit.

An early insight so far from the survey is that the effectiveness of physician communication determines how patients perceive the overall visit. Smith-Bentley said if patients don’t give the question regarding physician communication a high score, the overall rating of the visit drops by 30%.

“People value the (relationship with their provider) immensely, regardless of how they interact with them,” Vyas said.

In response to this finding, Stanford will begin training providers in communication skills during telehealth visits. The system is developing the content now, with the training available in early 2021.

“We are digging into a lot of the data but that was one early insight that we are taking action on immediately,” Smith-Bentley said.

Health system digital leaders say the ability to get data from the patient experience surveys immediately is key to improving telehealth platforms.

Since COVID-19, North Carolina-based Novant Health has added icons to its patient portal indicating if a visit will be done over video, phone or in-person, in response to feedback from patients in surveys that they were confused about what kind of visit they were having. Additionally, Novant has changed instructions on how to access virtual visits, creating detailed step-by-step guides as well as videos on its website demonstrating how they’re done.

“All (the changes) came from patient feedback,” said Dr. Hank Capps, Novant’s chief digital health and engagement officer.

The real-time feedback is possible because Novant has created its own survey, Capps added.

Vendors such as Press Ganey offer telehealth surveys but that approach is unappealing to some provider organizations. Hollander at Jefferson Health said the system prefers its own surveys because it gets results back right away when a patient completes the survey, allowing problems to be identified quickly. Jefferson can also change questions at any time. 

“I can decide tomorrow that everyone who comes in with a cough is asked, did you get antibiotics?” he said.

Still, Press Ganey has seen a significant increase in the use of its telehealth patient experience survey since COVID-19. From April 1 to Sept. 3, it administered 19.9 million telehealth surveys; in roughly the same period last year, Press Ganey sent out 23,000 surveys.

Press Ganey launched its telehealth survey about two years ago and it can be completed over email or text, said Chrissy Daniels, chief experience officer at the company.

Daniels said Press Ganey can customize survey items for customers, but system digital health officers still commented that the process is too slow compared with doing it in-house.

Baylor Scott & White Health is one of the health systems using Press Ganey’s telehealth survey and it works for them because patients’ experience with the virtual platform can be compared to in-person clinical visits, said Sunni Barnes, vice president of patient experience and consumer analytics.

The Dallas-based system has been using Press Ganey’s clinical visit survey for “many, many years,” Barnes said, so they have a stockpile of data to compare with the telehealth experience.

Another benefit to using a vendor is that Press Ganey offers reports analyzing how Baylor is performing on telehealth patient experience compared with its peers. “One of the advantages … is you get the benchmark capacity,” said Dr. Tiffany Berry, chief medical officer of the health system’s quality alliance.

The federal government is also jumping on the bandwagon of telehealth patient experience surveys. Modern Healthcare reported last month that the Agency for Healthcare Research and Quality will be releasing a beta version of a telehealth survey for providers to use sometime this month.

Digital leaders at health systems with a custom survey said the appeal of AHRQ creating a telehealth survey is the potential that the agency will publish results so providers can compare their performance with that of their peers.

“We want to have metrics that compare us to other health systems,” Hollander said. He added Jefferson would continue to use its custom survey for improvement work.

AHRQ’s telehealth survey is still in testing mode and therefore results won’t be publicly posted as is done for surveys from doctor’s office visits and health plans, said Caren Ginsberg, director of AHRQ’s Consumer Assessment of Healthcare Providers and Systems surveys program.

Stanford’s Smith-Bentley said although she is interested in the questions AHRQ has chosen to include and the survey’s design, a paper-based survey would be “silly.”

AHRQ hasn’t yet decided on the survey’s mode, but CMS collects surveys using paper and telephone, which is unpopular among providers.

Besides asking patients about their experience, health systems are also gauging feedback from staff members about how to improve the telehealth platform.

Jefferson has had a telehealth program for years, but only doctors willing and interested were participating. COVID-19 has brought on physicians who had no other choice as their clinics closed for in-person care in the early months of the pandemic.

Given that, Hollander said there was a lot of complaining from clinicians about what they thought was wrong with the platform.

“We designed an ideal use (of the platform) for people who wanted to use it, but we had to redefine ideal use for people who never wanted to be doing telemedicine but needed to,” he said.

Since COVID-19, a survey immediately after a visit asking questions about technical challenges goes to the provider in addition to the patient. The physician feedback has pushed leaders to make changes to the platform, such as removing the registration process for patients already in the system because it was redundant and time consuming.

Jefferson’s hiccup rate, which describes when a visit has technical glitches, is now under 10%, but for some providers it’s upwards of 30%. Hollander said Jefferson is now geocoding where providers are doing these visits to understand if it’s an issue the system can solve or something the provider might need to address, such as purchasing a more powerful router.

Hollander said it’s essential providers support the telemedicine experience because data show patients are more likely to use the platform if their provider recommends it.

“I need to make this a good experience for the providers so they can make it a good experience for the patients,” he said.