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The extensive uptake of telehealth has considerably transformed health care delivery since the beginning of the COVID-19 pandemic and has imposed tremendous challenges to its large-scale implementation and adaptation. Given the shift in paradigm from telehealth as an alternative mechanism of care delivery to telehealth as an integral part of the health system, it is imperative to take a systematic approach to identifying barriers to, opportunities for, and the overall impact of telehealth implementation amidst the current pandemic. In this work, we apply a human factors framework, the Systems Engineering Initiative for Patient Safety model, to guide our holistic analysis and discussion of telehealth implementation, encompassing the health care work system, care processes, and outcomes.
COVID-19, caused by the novel coronavirus SARS-CoV-2, has swept across the globe since its emergence in late 2019. The rapid spread of SARS-CoV-2 imposed an excessive burden on health care systems, with nearly 326.7 per 100,000 people in the USA requiring hospitalization through the end of 2020 [
The health care system is particularly vulnerable to novel and highly infectious agents such as SARS-CoV-2 because of the exponentially increased demand of health care resources [
The Systems Engineering Initiative for Patient Safety (SEIPS) model [
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The SEIPS model also emphasizes that the analysis of processes and outcomes should be based at both the individual level (ie, patients and health care workers) and the organizational level. For example, telehealth can reduce the burden of
Assessment of barriers related to and impact of telehealth implementation during the COVID-19 pandemic by using the Systems Engineering Initiative for Patient Safety (SEIPS) model.
Domain and components | Impact | Issues | ||
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Person as patients |
Increased acceptance of telehealth due to convenience |
Insufficient and variable levels of digital literacy among the patient population Widening of health care disparities [ |
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Person as providers |
Increased motivation Alleviation of workforce shortage due to the quarantine |
Mental or physical challenges due to the imperative and wide adoption of telehealth |
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Technologies and tools |
Enhanced patient and health care worker safety Conserve PPEa |
Telehealth may be disruptive and not user-friendly |
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Environment |
Highlighted the suboptimal and complex environment for telehealth uptake |
Insufficient communication infrastructure The environment where patients interact with telehealth technology may be suboptimal |
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Tasks for patients |
Safer and potentially quicker access to care |
Systemic, informational, procedural gap that patients need to fill in |
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Tasks for providers |
Clinical and nonclinical services can be safely continued via telehealth |
Challenges in adapting to changes in job content and demands |
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Organization |
Formulation of new teams Maximizing the utilization of existing resources to deal with the pandemic |
Dynamic changes to teamwork Reallocation of accountability and responsibility Redistribution of labor, equipment, information, and funding resources |
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Care Processes |
Wide application of forward-triage, tele-intake, and tele-ICUb Increase in web-based visits replacing in-person visits and mixed processes (ie, some in-person visits and some televisits) |
Time management is more challenging (eg, a busy lobby makes it easier to accept the physician being late as opposed to being at home waiting alone in the virtual lobby) Telehealth may not lead to a shorter overall time spent in the care system |
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Other processes |
Reduced demand of other processes that support care processes (eg, reduced environment disinfection needs due to the fewer in-person visits) |
Information flow may be more fragmented |
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Patients’ outcomes | Unclear |
Lack of measures for patient safety and quality of care evaluation |
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Care providers’ and organizational outcomes | Unclear |
Lack of measures for assessing care providers’ mental and physical health affected by the surging use of telehealth during the COVID-19 pandemic Organizational outcome related to the pandemic-driven, large-scale uptake of telehealth needs more attention |
aPPE: personal protective equipment.
bICU: intensive care unit.
During various stages of the COVID-19 pandemic, many health care providers were quarantined after potential exposure to or confirmed infection with the virus, resulting in a limited workforce and a reduced health care system capacity. Telehealth can facilitate the rearrangement and reassignment of the workforce and maintain the capacity by allowing quarantined health care providers to continue their work without compromising the health care system’s safety. Moreover, care facilities that lack telemedicine programs can outsource part of their services to entities with well-established telemedicine programs to meet these goals [
Despite the claimed benefits of efficiency and convenience offered by telehealth, not all health care providers have been satisfied with the telehealth options available, even before the COVID-19 pandemic. Preliminary reports from the early phases of the pandemic [
Patients, on the other hand, are also profoundly influenced by the imperative uptake of telehealth since the beginning of the pandemic. Recent studies have shown that telehealth approaches such as remote video visits in a variety of care delivery contexts is acceptable to patients [
Prior to the COVID-19 pandemic, telehealth was regarded as an alternative form of care delivery to in-person care. It was considered ancillary because telehealth was not widely possible until the widespread prevalence of smartphones [
A recent study pointed out that the adoption of telehealth can conserve PPE [
Despite the benefits of telehealth uptake, we cannot assume it would work well within the current health care system. In fact, the telehealth system is deemed as disruptive and not user-friendly by many clinicians [
Despite the convenience that telehealth can provide, the lack of infrastructure and insufficient technical capability may limit providers’ and patients’ use and acceptance of telehealth. Although the majority of the United States has access to 4G or faster networks, many remote and rural regions still lag behind in terms of internet coverage. A report from the American Hospital Association shows that 34 million Americans do not have access to satisfactory broadband [
The COVID-19 pandemic may have also changed the environment wherein the patient usually uses telehealth. The environment in which patients interact with telehealth technology may be suboptimal. The shelter-in-place orders compelled people to stay in their residential living spaces. The lighting, noise level, and airflow in residential living spaces may not be ideal for medical consultation via telemedicine. For example, childcare and at-home responsibilities may interfere with the interaction with providers via telemedicine, especially regarding sensitive issues. Such environmental factors are less often explored by studies but are still demanded important for satisfactory telehealth use [
Telehealth can facilitate the delivery of clinical and nonclinical services [
The widespread adoption of telehealth to deliver care during the COVID-19 pandemic has changed the care delivery protocols [
Current telehealth practices have also disrupted care providers’ workflow and work content [
During the COVID-19 pandemic, many facilities were required to form new teams that were specifically designated to tackle all COVID-19–related activities, including care coordination. For instance, an academic medical center in San Diego formed an “Ambulatory COVID Team (ACT)” consisting of seven care providers, including physicians, nurses, epidemiology experts, and administrative officers [
Considering e-ICU programs as an example of telehealth, several programs provided services to allow physicians and nurses to remotely monitor patients in ICUs across several hospitals [
In addition to the numerous changes telehealth could possibly contribute to the teamwork dynamics, it could also play a role in resource reallocation within the system. Resources in health systems usually include labor resources (ie, a variety of care providers and administrative staff), equipment resources (ie, ventilator, PPE, and computers), information resources (ie, patient information), and funding resources (ie, payment and reimbursement).
Telehealth can conserve valuable labor resources and maximize the use of available human resources by (1) protecting health care providers from potential exposure to COVID-19; (2) allowing health care providers with suspected exposure to COVID-19 to continue working, who may otherwise have to be self-isolated [
Telehealth use was mostly restricted to patients living in remote areas or staying in the health care facilities [
The pandemic-driven telehealth uptake also heightened the information flow problem more than ever before. A COVID-19 care management pathway enabled by telehealth can connect many health care entities for triaging, screening, and treatment through telehealth or onsite outpatient visits, specimen collection (onsite or drive-through), clinical testing laboratories, follow-up with primary care or appropriate care providers, and inpatient care [
The clinical care processes of COVID-19 typically consist of four stages: screening, testing, treatment, and recovery. During the screening stage, forward triage is deemed as an important practice to relieve the intake pressure on the health care facility’s front end [
While telehealth had manifested its potential in allowing patients quicker access to care, it also imposed a higher requirement for care providers’ time management. A traditional busy lobby usually made it easier to accept if the physicians were late to the appointments; however, patients waiting alone on a web-based platform and not being able to see the bustle on the side of care providers could make the care experience less patient-centered. Hence, an ideal telehealth system design would allow care providers to better engage patients and improve their care experience before and after the televisit.
In terms of other processes that support care processes, telehealth may exhibit different effects. For example, with fewer in-person visits, the stress and demand of repetitive environment disinfection could be relatively relieved. However, telehealth could also impose extra challenges of integrating, maintaining, and transferring of patient information.
Regulation and policy changes that have come into effect during the pandemic may be perceived as the driving force for the large-scale uptake of telehealth. However, for longer-term sustainability, performance-based outcome metrics are needed to assess the impact of telehealth on health systems. A few studies have made initial attempts to apply existing performance metrics to assess telehealth implementation [
Potential outcome measures of telehealth-enabled care.
Outcome level and dimension | Potential outcome measures | |
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Patient safety |
Diagnostic errors (compared to in-person visits) Hospitalization rate ICUa admission rate Intubation rate Mortality rate (general and ICU) Readmission rate Health care–associated infections |
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Care quality |
Left without being seen Door-to-provider and door-to-disposition times Left without treatment complete Left against medical advice Left without treatment [ |
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Work safety |
Work-associated infections PPEb sufficiency |
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Work quality |
Work stress and clinician burnout Work efficiency |
Organizational outcome |
Staff turnover rate Policy implementation performance Finance health index (before and after the COVID-19 pandemic) |
aICU: intensive care unit.
bPPE: personal protective equipment.
The COVID-19 pandemic has thrust telehealth solutions into the front line of health care despite significant barriers to its effective implementation and optimization. There are significant benefits to utilizing telehealth, namely providing enhanced safety options for patients and health care providers during the pandemic and introducing the potential to enhance efficiency and convenience in the future. However, challenges with telehealth implementation arising in different domains of health care work system and processes that potentiate disruption to care delivery, worsen disparities in health care, and provoke changes from different levels within the health care industry, still need to be addressed. Future efforts should therefore address these barriers to implementation by redesigning telehealth solutions via a systematic approach such that health care systems can mitigate the negative effects of telehealth and seamlessly realize the benefits and enhanced safety that telehealth provides.
electronic intensive care unit
intensive care unit
personal protective equipment
Systems Engineering Initiative for Patient Safety Model
This work for supported in part by the National Science Foundation under grant #1838745 and the State of Arizona Technology and Research Initiative Fund (TRIF).
None declared.