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Main Takeaway from Research:

The purpose of this literature review is to explore how to have an effective telepresence. Telepresence is operationally defined as, “a virtual presence created by a healthcare provider that encompasses interpersonal, environmental, and technological factors”. With the recent growth in telemedicine this is important for every healthcare professional utilizing telemedicine. As a result of the literature review three themes were identified as variables that contribute to an effective telepresence: (1) interpersonal skills of the clinician, (2) preparation and environment, and (3) technology-related factors.

 

Comprehensive Literature Review:

Effective Telepresence

Over the past decade, and especially over the last few months, the utilization of telemedicine in the healthcare setting has become much more prevalent (Calton, et al., 2020). Telemedicine uses various forms of technology, such as video or audio calls, computers, etc., to deliver healthcare services (Darkins & Cary, 2000). Services can either be provided between a healthcare provider and a patient located remotely, or the technology can be used for healthcare providers and specialists to collaborate and interact with each other surrounding patient care (Darkins & Cary, 2000). With telemedicine being implemented across various healthcare settings, it is important to recognize potential benefits, as well as barriers, this modality of service may offer.

One component of telemedicine that should be considered is the idea of “telepresence”. For the sake of this literature review, “telepresence” is operationally defined by the authors as “a virtual presence created by a healthcare provider that encompasses interpersonal, environmental, and technological factors”. “Effective telepresence” would relate to a healthcare provider’s ability to incorporate all these components and integrate them into their practice, to ensure the most beneficial virtual experience for the patient. LeRouge et al. (2014) describe telepresence as a “virtual bedside manner”.

A literature review was conducted in order to determine what components contributed to an “effective telepresence”. As a result, three themes emerged: (1) interpersonal skills of the clinician, (2) preparation and environment, and (3) technology-related factors. This paper aims to discuss each of the themes and how they may contribute to an effective telepresence for healthcare providers.

 

Interpersonal Skills of Clinician

The first theme, which was a focus in most of the literature, is surrounding interpersonal skills of the clinician. These skills are often some of the most basic skills learned by healthcare professionals, but it is important that they are also being implemented in virtual interactions. Henry et al. (2016) discusses many of these clinician behaviors in their study. To start, they found that a positive attitude by the clinician about telemedicine can help to lessen some of the drawbacks that can occur such as glitches with technology. Henry et al. (2016) also reported and emphasized the importance of building rapport with the patient. Just like in-person care, establishing a relationship with your patients can make the whole experience a lot more pleasant for all parties involved. Pellegrino and Kobb (2005) also studied what kind of skills are needed for a successful telemedicine interaction and found that interpersonal skills were hugely important. They found that personality traits such as compassion, adaptability, persistence, optimism, advocacy, resourcefulness and flexibility were all essential for a successful telemedicine experience (Pellegrino & Kobb, 2005). 

Clear and skilled communication over telemedicine meetings is also key to help minimize confusion from the patient. This can go both ways, but it is important that the clinician takes the time to understand the entire message and ask clarifying questions when not sure of what the patient is communicating (Henry et al., 2016). Nestel et al. (2007) touch on how communication via technology can often distort and even eliminate some non-verbal communication cues such as gaze, eye contact, body language and lip reading. When using telemedicine for bedside consultations, they found that it required more patient effort to pick up on these non-verbal cues (Nestel et al., 2007).  Cues are a large part of communication and visual cues may help the patient understand the interaction, particularly over telemedicine. This may include providing a written outline of the talking points for the meeting, referencing graphics or figures, or other visual cues to help ensure clear communication.

Telemedicine can be challenging for all parties, so it is crucial to have patience as a healthcare provider. Calton et al. (2020) stress the importance of patience by explaining that whether it is with technical difficulties, or the patients needing extra time to process information, having patience with your patient supports an effective interaction. Miller (2001) reported that during telemedicine meetings, providers controlled the conversation and overall spoke more than the patients during the encounter. This is also the case for in-person interactions; however, it was also found that patients were even more passive in telemedicine interactions compared to in-person appointments (Miller, 2001). This reinforces the need to be especially mindful that the patient may need time or probing to communicate his/her questions and concerns. After all, every meeting should be patient-centered and it is important that the patient is getting the most out of the experience (Crossen et al., 2020). A large benefit of telemedicine is the patient having the ability to be very active in their healthcare process and decision making. 

Preparation and Environment

As previously mentioned, every meeting should be patient-centered and therefore focused on discussing the patient’s health needs. Healthcare providers must be clear and use the time effectively to address all of these needs. Many distracting barriers can be eliminated simply by addressing components of the second theme: preparation and environment. Before telemedicine meetings even begin, the literature suggests that there are several things that can be addressed to ensure all parties are on the same page. First and foremost, all parties should be able and comfortable with utilizing the technology in the most effective way. Calton et al. (2020) suggests having something available to the patient before the first session that explains the session goals and the technology being used, including how to download it. LeRouge et al. (2014) also suggests establishing a point person for the patient to contact in case there are any technology-related barriers that occur. In a study done by LeRouge et al. (2014), patients communicated that it was important that technology should not get in the way of patient care, and that meetings should be spent discussing health needs and not troubleshooting technology barriers. 

Having clear expectations for the interaction beforehand may also help to eliminate confusion. Both Crossen et al. (2020) and Henry et al. (2016) discuss the idea of standardization of telemedicine visits. This means that the patient knows what to expect because it is the same process each time, including any responsibilities before/after the meeting. Patients surveyed in LeRouge et al. (2014) also stressed that when providers established clear directives for the meeting, it was a more positive experience. Providers should be prepared with talking points, have previously coordinated with the medical team, and leave time for patient questions and feedback. A prepared and organized provider better ensure that all health needs can be addressed during the meeting, and this efficacy allows for more time for the patient to give any input they have. Planning not only for individual meetings, but for the entire day is also important. With technology comes possible delays, so giving time in between meetings to assure not being late to the next one helps you be completely compared for the next session (Calton, et al., 2020). 

Henry et al. (2016) also discusses how the clinician’s surroundings and environment may impact the telemedicine experience. This study mentions taking steps like wearing headphones and assuring the patient that no one else is in the room can ensure confidentiality and aid in patient comfort. Patients from the LeRouge et al. (2014) study also share that the provider’s environment should have adequate lighting, be quiet, and have a professional (not distracting) background. These can all help assure the patient that the session is private and helps establish professionalism.

Technology-Related Factors

Since telemedicine is accomplished using technology, the third and final theme discusses the importance of addressing technology-related factors. Previous sections touch upon ensuring all parties are comfortable and educated on how to utilize the technology efficiently. It has also been established that providers should have an environment that allows communication to be clear, and what steps can be taken to provide clear communication. Aside from this, LeRouge et al. (2014) also shares that patients find it important that the actual technology functioning is adequate for interactions. This includes, but is not limited to, having adequate image resolution for video, clear audio, and using a reliable and affordable resource (LeRouge et al., 2014). The microphone and camera are both vital parts of telemedicine however if a video-call is not available, providers should be ready to use a phone call instead (Crossen et al., 2020). Although not every session/meeting is the same, teaching the patient about the technology, such as muting themselves while not speaking during a group meeting, is paramount (Calton et al., 2020).

Maintaining patient confidentiality is mandatory, even through telemedicine. In addition to establishing a private environment, the software that is used for these meetings must be Health Insurance Portability and Accountability Act (HIPAA) compliant. (Crossen, et al, 2020). The privacy of the patient is always the priority in any healthcare interaction, and if there are other resources being used over telemedicine meetings they all need to be secure and private as well (Calton et al., 2020). Assuring that the patient feels prepared for any technology being used, and that this technology is efficient and confidential, is vital for success.

Conclusion

Even though these studies did outline different variables that could result in a more effective telepresence, limitations and gaps in the research were identified. As of 2016, the research stated that there was no consensus on what telemedicine education for providers needed to include (Henry et al., 2016). Across the studies included in this literature review none of them explained any overarching criteria for telemedicine education, which is problematic in a time where it is relied on so heavily in various professions. The hope is that this can be established, solidified, and streamlined to create a standardization of what education is necessary to ensure professionals are conducting safe, ethical, and effective telemedicine meetings with their patients. Nonetheless this literature review supports that the integration of strong interpersonal skills, preparing and optimizing your environment, and controlling for technology-related factors can be correlated with an effective telepresence and a positive telemedicine experience between all parties involved. 

Heather Lowry, B.A.

 

Sarah Wildes, B.S.