To see all of the feature stories in the Burnout in the Age of COVID-19 series, click here.

In 2020, telemedicine truly, finally hit the mainstream in the United States. The COVID-19 pandemic essentially forced healthcare provider organizations, the government and payers to embrace telehealth as an essential way to enable physicians to see patients.

With much of the country shut down earlier this year, the typical number of weekly virtual care visits grew from dozens, to hundreds, to thousands at hospitals and health systems across the country.

This put a lot of pressure on the physicians who oversee telehealth programs at these providers: the telehealth managers.

This is the sixth article in Healthcare IT News’ Burnout in the Age of COVID-19 feature story series, and it focuses on the kinds of stresses telehealth managers face, how telehealth technology hurts managers’ abilities to cope with those stressors and how telemedicine tech helps them manage stress.

Here, five physician telehealth managers tell their stories.

How stress manifested as telehealth visits boomed

When COVID-19 hit, CareMount Medical, the largest independent multispecialty medical group in New York State, with more than 650 physicians, recognized the need to restrict in-office visits and make some rapid changes to its telehealth approach.

“We already had an established telehealth platform in place that our patients could use, but the challenge was to increase our capacity in a very quick time frame,” said Dr. Lisa R. Bardack, medical director of CareMount Medical and chair of the department of internal medicine/endocrine/rheumatology.

“Normally, it would have taken three to six months to roll out this type of platform to more than 650 providers, but we did it in less than two weeks – a testament to our amazing leadership and staff. The most difficult aspect was deploying the technology to be effective and efficient for both patients and providers.”

"We recognized the need to switch to a new telehealth platform that is integrated into our electronic health record, making the whole process much easier and more efficient."

Dr. Lisa R. Bardack, CareMount Medical

This was all very new to patients, who already had the stress of the pandemic as a constant in their lives, she added. They would get frustrated with connectivity issues, inputting information and testing the devices. CareMount also experienced some difficulties with app access from an audio/visual perspective.

“Ultimately, we recognized the need to switch to a new telehealth platform that is integrated into our electronic health record, making the whole process much easier and more efficient,” Bardack explained.

“I can now self-schedule, and see when the patient has checked in, and when they’re ready and waiting for me,” she said. Patients check in online, which gets everything else in place to run smoothly, such as having the EHR ready, the documentation in the right place, and everything integrated for billing. The new technology has definitely helped to reduce provider stress.”

Telehealth itself adds stress to the mix

The uncertainty of the coronavirus and changing guidance from the government made for a very stressful time, said Dr. Bradley Crotty, chief digital engagement officer and an internist at Froedtert & the Medical College of Wisconsin regional health network.

“Clinicians were concerned about taking care of their patients, while minimizing avoidable risks,” he said. “Clinicians and healthcare organizations rose to the challenge, though, in being open to and adopting virtual care while ensuring that patients could still access in-person care when needed.”

Telehealth added new stress into the mix, he said.

"We rapidly scaled our telehealth solution from primary care to all specialty care in a span of less than two weeks."

Dr. Bradley Crotty, Froedtert & the Medical College of Wisconsin health network

“For most clinicians, and patients, this was their first experience with virtual care,” he said. “Everyone was learning the technology, the workflows, and becoming accustomed to care at a distance. In our case, we rapidly scaled our telehealth solution from primary care to all specialty care in a span of less than two weeks, including cancer, orthopedics, physical therapy, as well as additional services such as genetic counseling and nurse education.”

The health network also moved from having early adopters being the ones to choose consumer telemedicine to delivering telehealth virtually by default.

“Many patients and clinicians were forgiving of the initial bumps with such a fast transition to virtual care, but became less understanding as time went on,” Crotty noted. “We had to move to a new cloud video provider because our volume of virtual exploded, and this created challenges along the way to more seamlessly integrate video into our electronic health record and digital care experience.”

The organization’s physicians told Crotty and staff “it just has to work” so they could focus on patient care rather than the technology.

Stressors from COVID-19 and virtual care

For healthcare providers, the first stress was from COVID-19 itself – stress regarding their patients’ safety, stress regarding their own exposure and safety, stress involving their colleagues’ exposure and safety, and stress about amounts of PPE that their institutions could provide, said Dr. Caitlin Sgarlat Deluca, information technology physician advisor at Upstate Medical University in Syracuse, New York.

“More stress came of course when we all needed to quickly shift patient schedules into new templates that would allow for providers to see patients through telemedicine visits though also allow in-office patient visits when needed,” she said.

"Telemedicine also can add to patient burden and frustration, which can add to a provider’s stress."

Dr. Caitlin Sgarlat Deluca, Upstate Medical University

“This needed to be coordinated with our entire clinic, with six subspecialty providers, in a way for everything to flow. Patients had to be cancelled for a couple of weeks at first while this plan was created and put into place.”

The next stress came with learning the ins and outs of what went into a telemedicine visit, she continued.

“Technology was quickly implemented by our IMT department with recommended workflows. Our IMT department really did an amazing job with implementation,” Sgarlat noted. “These workflows were adapted for our area with the entire clinical team, including nursing, front desk staff, MOAs and, of course, providers. The technology had to be learned, and also had to be communicated to patients for their end of it.”

The stress of all of this was real, and so was potential burnout, she said.

“I do think that once the plans and workflows were in place, and the technology was learned, many of these stressors melted away,” she recalled. “The entire process seems to have brought our clinical team together stronger. Cooperation from everyone was key, and that quickly became apparent.”

Still processing the telehealth explosion

Dr. Chris Davis, an emergency medicine specialist and medical director of UCHealth Virtual Health at Colorado’s UCHealth, said he still is processing the explosion in telehealth demand that providers all lived through during the early days of the pandemic.

“Even before SARS CoV-2, many operational leaders could intuitively see the utility of telehealth during a pandemic or disaster, but I don’t think anyone predicted the scale of growth we saw in March,” he observed. “Personally, I certainly did not predict to see 900% volume growth in our virtual urgent care over a period of 10 days.”

"Personally, I certainly did not predict to see 900% volume growth in our virtual urgent care over a period of 10 days."

Dr. Chris Davis, UCHealth

Riding that kind of growth curve was incredibly stressful for Davis and his colleagues.

“But what I will say is that time period represented the most important work I’ve ever accomplished, and I’m so proud to be part of the team that is so vital to our pandemic response,” he said.

“During that first surge, the main stressor was finding and then onboarding providers into our virtual care environment – the demand for virtual visits was staggering.”

It was incredibly frenetic as UCHealth temporarily closed some brick-and-mortar facilities to shift resources to the Virtual Health Center.

“A new provider would show up for training, and IT would still be building out their workstations in our command hub,” he remembered. “It was at once the most fun and the most terrifying work experience I’ve ever had. As an emergency physician, that’s saying something.”

Ways telemedicine tech can hurt ability to cope

So COVID-19 hit, then telemedicine hit. While telemedicine technology was a godsend during this pandemic, it did come with aspects that hurt providers’ ability to cope with the kinds of stress that lead to burnout.

Telemedicine can hurt coping with stress in several ways, said Deluca of Upstate Medical University. With telemedicine, a provider often is isolated from clinical staff. Deluca finds that socialization (safely, of course, under current circumstances) helps with stress. Trying to make light of things with others, joking and connecting all help decrease stress, she said. And that’s difficult to do when isolated.

“Telemedicine also can add to patient burden and frustration, which can add to a provider’s stress,” she said. “Many patients do not have access to a smartphone or a computer and rely on telephone telemedicine encounters, which are not ideal in many situations. A patient’s stress with the technology also can add to a provider’s stress in helping and treating the patient.”

With telephone telemedicine encounters, not being able to see the patient really decreases the connection between a provider and patient, also adding stress, she noted.

That sense of team

Fundamentally, the pandemic is a lonely time, said Davis of UCHealth. When UCHealth sent providers home to deliver care virtually, providers lost some of those day-to-day interactions that lead to a sense of team. Shared experience and camaraderie are critical for resiliency, he said. That sense of team is harder to engender with providers working from home, he added.

“Also, while the IT infrastructure that supported our telehealth program was impressively reliable, technology is not foolproof, and, when things did go wrong, the wheels could fall off quickly,” he said. “For providers, this manifested as a loss of control. If the technology was not working, it made patient care incredibly difficult. We learned a lot of lessons around operational redundancy in those early days.”

Crotty, of Froedtert & the Medical College of Wisconsin, saw “friction” on the way toward the adoption of virtual care.

“And the friction began to add up,” he recalled. “For clinicians, it was learning the ropes of a new care medium and a new technology. If the video connection didn’t work, was pixelated, or had audio lag, distortion, or other problems, then it really wasn’t practical for care. Patients had trouble learning how to sign on to video visits, or had unstable network connections that led to either choppy or dropped connections. Sometimes they didn’t have network access at all.”

Crotty and his team also were concerned from a health equity perspective that they would not be able to reach all patients, so they maintained telephone-based calls, as well as adopting other video platforms that made the connections easier.

“Our clinicians found it very stressful to stay on time in the clinic while troubleshooting all of these challenges,” he said. “Personally, there was an instance where both a patient and I were undertaking a Herculean task to connect virtually late on a Friday so that I could examine them for a new concern. I think the patient was ultimately more frustrated than me, and eventually we had to settle for doing what we could by phone and then picking back up in person the following week.”

Joy in medical practice comes from making meaningful connections – but that joy can erode if days are spent just trying to get technically connected, he said.

“We tracked our successes and difficulties carefully, and we made a very significant improvement over a short amount of time,” said Crotty. “Our patients for the most part took it in stride, with our video visits being one of our most positive patient experiences.”

Three stressors unique to telehealth

Bardack of CareMount Medical cites three major aspects of using a telehealth platform that can increase stress.

“First, when a technology glitch occurs during the visit and you can no longer hear or see the patient, or the patient can no longer hear or see you, it is frustrating for both the provider and the patient,” she said. “That is something that never occurs when you’re in an exam room, but is a variable when using technology.”

Second, inappropriate triage: CareMount had to create new, clinically appropriate criteria for telehealth visits to assess what could be done remotely and what required an in-person visit.

“We’ve always had to make triage decisions and decide if a patient’s condition is appropriate for the office, or if they needed to go to the emergency room,” she explained.

“Triaging for telehealth is very new, however, and when triage mistakes occur, it can really raise stress levels. If you’re in an appointment with a patient and realize it may not be the appropriate appointment setting, you then have to quickly think through how to best take care of the patient – either in the office today, or wait until tomorrow, or send him to get a blood test or an X-ray. These are all new decision points for providers.”

Third, there is much less of a buffer when a patient or a doctor is running late.

“If I am running late, I may not have anyone who can tell the patient what is going on,” she noted. “The patient might become stressed sitting at home wondering if the technology is working or if the doctor forgot about her. From the doctor’s perspective, I’m stressed because I know someone’s waiting for me on her telehealth visit, but I’m not finished with the previous patient. With telehealth visits, you need more precision with your schedule.”

A tiring new way to communicate

Telemedicine adversely affects one’s capacity to cope with stress that can lead to burnout due to the lack of human contact and the effort to communicate in a new way, which can be tiring, said Dr. Ari Kalechstein, president and CEO of Executive Mental Health in Los Angeles.

“Oftentimes, doctors who rely on telehealth media to provide patient care lack the human contact that one receives when providing face-to-face care,” he said. “The lack of face-to-face contact creates concern that we might miss some sort of important nonverbal behavior, such as a gesture or a facial expression that may be outside the frame of the camera or not easily detected. In addition, we lose a degree of closeness with the person to whom we are communicating.”

"The lack of face-to-face contact creates concern that we might miss some sort of important nonverbal behavior."

Dr. Ari Kalechstein, Executive Mental Health

Executive Mental Health’s experience with telehealth has been that it takes more effort to communicate.

“For example, it is important to be cognizant of ensuring that one is sitting in front of the camera, speaking clearly and at a modest pace,” he said. “We also need to work to take turns during colloquy, something which comes more naturally when in person. At times, people may inadvertently speak over each other because the timing on a telehealth conference is different than that in a face-to-face setting.”

How virtual care technology helps telehealth managers cope

While telehealth technology can add to caregivers’ burdens when it comes to stress and burnout, more important, it can help relieve stress that can lead to burnout.

In the same way that telemedicine is more convenient for patients, it can also be more convenient for providers, too, said Davis of UCHealth.

“Convenience can make things less stressful, which can help contribute to reduced chance for burnout,” he said. “For most, working from home meant no painful commute and a cozier work environment. We heard from most of our providers that working from home was an enormous win.”

The key is recognizing when this does not hold true, he added. Some providers wanted to come into UCHealth’s Virtual Health Center, usually because their home environment was too noisy or chaotic. Maintaining that operational flexibility was key, he revealed.

Picking up the kids

Telemedicine can be very helpful and stress-reducing in many ways: It is very convenient to be able to take care of patients from any physical location, said Deluca of Upstate Medical University.

“This greatly reduces stress with busy schedules and other personal commitments that might be new during this COVID-19 pandemic, such as family responsibilities,” she said.

“In my own life, telemedicine technology has helped me adjust my schedule for child care at certain times of the day for my two children. I do most of my visits from my clinic, though I often finish with patient care after I pick my children up from their babysitter, where they go after school. The technology allows me to have both telephone and telemedicine video visits from home, if needed.”

Virtual care is really rewarding, said Crotty of Froedtert and the Medical College of Wisconsin.

“We have seen how we can more easily see patients quickly when needed, and at a higher convenience level for the patient,” he said. “Especially among patients where transportation can be challenging, we can more easily take care of issues at hand.”

Burnout has more to do with clinicians feeling they need to focus more on administrative tasks than patient care, he added.

“Telehealth can help restore that attention back to the patient,” he noted. “And we have seen so many wins, including: patients who have been able to have smoking cessation counseling sessions while on a work break; patients who have had their rash quickly evaluated virtually, avoiding delays in care; and patients where transportation is difficult, but they could be seen same-day for urgent needs.”

Preparation goes a long way to having successful connections and increasing the benefit, while mitigating the friction, he said. For patients, this is ensuring they have a stable network connection, have been guided into any steps to get connected, and are stationary rather than walking, or, worse, in a car or train, he said.

“For clinicians, having well-established fallback plans for when something does not go smoothly, such as switching to a phone call, can take the pressure off,” he added.

Providing a safe workplace

One way telemedicine technology helps reduce stress, which may be intuitive: When care is delivered remotely, there is less work-related risk of COVID-19, said Davis of UCHealth.

“Having a robust telemedicine program allowed us to have a work environment where our high-risk providers – older, immunocompromised or pregnant – could contribute safely to the pandemic response,” he said. “Giving this high-risk provider group an avenue with a much reduced risk of exposure was a big win for these providers. Again, it’s all about operational flexibility.”

Another intuitive win: Telemedicine also can be a way to see patients who are unable to come to the clinic, said Deluca of Upstate Medical University.

“Some patients live hours away from our clinic,” she explained. “Some patients are immunocompromised and need to shelter at home in this unprecedented time. Many of my patients are thrilled that they are able to have a visit with me from their homes. Connecting with my patients and taking care of them as it is convenient for them reduces my stress and actually brings me great joy.”

Restoring the work/life balance

On another front, telehealth technology can help restore some work-life balance for clinicians, said Crotty of Froedtert and the Medical College of Wisconsin.

“We have seen where clinicians are benefiting from having remote clinic sessions that can be done in their home, saving commuting time,” he noted. “For clinicians with families, this may be especially helpful to stay in balance. Our academic clinicians also have been able to provide virtual care outside of their usual clinical hours when they are able to do so, helping them balance patient needs and continuity of care without the constraints of clinic space or traveling to a clinical location.”

Overall, Executive Mental Health views telehealth as an approach that, when applied properly, creates advantages for clinicians and eradicates obstacles that interfere with the provision of care, Kalechstein stated.

“Some of the advantages are logistical, and include the elimination of a commute to work and the associated costs,” he said. “Reduced commuter time means reduced stress: The elimination of the commute means that clinicians potentially will have more time to engage in productive and desired activities, such as exercise, spending time with family and enjoying a hobby.”

In addition, teams can benefit from telehealth as they get quicker responses to referral requests from partner facilities, he added. Finally, telehealth facilitates the possibility of providing care to patients who reside in areas that are less accessible, like rural areas, he said.

In closing, six stress-reducing factors

Bardack of CareMount Medical closes things off with six aspects of telemedicine that she notes reduce stress that can lead to burnout.

“One very simple way telehealth visits help reduce my stress is my ability to do visits without wearing PPE,” she explained. “I can take my mask off. I can take my goggles off. My face can breathe, and I can have a conversation where someone can see my mouth and she is not wearing a mask.”

On another note, patients tend to be more relaxed during telehealth visits than in office visits, she observed.

“Doctors’ offices can be stressful places for patients,” she said. “When patients are more relaxed, so are doctors. There are fewer variables that may cause an appointment to be delayed and the visits are just me and my patient – which I love. Telehealth visits strip things down to a simpler level, often making both patients and the provider more relaxed.”

Another positive aspect about telehealth is that it can be done from anywhere at any time of day, she said. Bardack can do visits from her office or her home, sometimes on weekends or in the evenings, which makes it easier to fit patients into her schedule and reduces stress. It also can be more convenient for patients, because they do not have to juggle their work schedules.

“Having a telehealth platform also reduces the stress of having to take care of out-of-office tasks, such as phone calls to patients,” she said. “I can turn phone calls into telehealth visits, which are longer and more comprehensive. For example, if a patient’s blood tests come back and I need to discuss with him how to manage high cholesterol, I can schedule a telehealth visit instead of playing phone tag. A telehealth visit is much more effective, less stressful, and improves a patient’s engagement with their health.”

Telehealth adoption also decreases exposure for contagious infections, she noted.

“This minimizes stress for physicians and patients,” she said. “If you have a patient who you think might be contagious and doesn’t seem to have the types of symptoms that absolutely require a physical exam, I recommend taking advantage of telehealth to triage the patient. We’ve had success using telehealth to evaluate whether or not someone may have COVID-19, if she may need to be seen in person, or if it’s better for her to stay at home and wait and see.”

Finally, Bardack recommends setting aside a block of time in the week just for telehealth visits.

“There’s a rhythm to telehealth visits, and if you don’t have to run back and forth from the exam room to telehealth visits, you are more likely to stay on time,” she advised.

“You can get into your telehealth block, find a comfortable place to sit, take off your PPE and just care for patients. You also can reduce stress by getting a good handle on the types of appointments that are most appropriate for telehealth, like reviewing abnormal lab results with patients.”

Another type of visit that lends itself well to telehealth is a discussion about anxiety, depression or insomnia, she added.

“These types of visits are more of ... counseling [sessions] that do not require a physical exam,” she concluded, “and patients are much more comfortable having these conversations from a private setting like their home instead of an exam room.”

Watch in the coming weeks for our next installment in the Burnout in the Age of COVID-19 feature story series, focusing on progress in EHR and other health IT usability to prevent IT burnout.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.