Attitudes toward the use of telehealth differ markedly among mental health, primary care, and specialty care clinicians, according to a new study that involved eight clinics of the Department of Veterans Affairs (VA) New England Healthcare System.
Mental health professionals used telehealth — including phone and video visits — far more than did either primary or specialty care clinicians. For example, video encounters comprised 40.3% of mental health encounters, compared to 3.9% and 4.9% of primary and specialty care encounters, respectively, according to the study, which was based on VA utilization data for August and September 2021. Primary care clinicians, however, performed the highest percentage of phone visits with established patients at 8.3%, vs 7.2% for mental health clinicians and 6.4% for specialists.
The researchers also conducted a survey of 866 clinicians. Of these professionals, 52 reported no video or phone telehealth use in the prior 3 months and were excluded from the results.
Physicians constituted about 40% of the sample. Other clinicians included psychologists, social workers, nurse practitioners, pharmacists, physician assistants, and podiatrists.
During the 3 months prior to survey completion, 701 clinicians (86.1%) conducted at least one phone appointment, and 730 clinicians (88.5%) conducted a video visit. Mental health clinicians were the most likely to have completed a video appointment: 95.8% had done so, compared to 89.5% of primary care clinicians and 76.4% of specialty care clinicians.
In contrast, just 78.5% of mental health clinicians had conducted a phone visit, vs 97.4% of primary care clinicians and 91.5% of specialists.
Telehealth Viewed Differently for Established vs New Patients
The study found a significant difference in attitudes toward the use of telehealth to treat established and new patients. “Clinicians were significantly more likely to rate video care and phone care as equivalent to or higher in quality than in-person care with masks when treating established patients compared with new patients,” the researchers note.
Clinicians’ quality ratings of video care compared to in-person care for new patients were highest for mental health, intermediate for primary care, and lowest for specialty care. There was much less variation among the three specialty areas in their attitudes toward the quality of phone care vs in-person care for both new and established patients.
Less than a third of clinicians (32.1%) rated phone care as equivalent to or higher in quality than video when treating new patients. But far more respondents found phone care acceptable for established patients.
Clinicians are more likely to embrace telehealth for established patients than new ones simply because they’re more comfortable with that, according to lead study author Samantha Connolly, PhD, a researcher and clinical psychologist in the VA Boston healthcare system and an assistant professor at Harvard Medical School.
“Some providers feel if they’ve met their patient in person — and for primary care and specialty care clinicians, if they’ve conducted a physical exam in the past —they feel more confident to follow up with that patient remotely, because they’ve seen them in person before,” she told Medscape Medical News. “With a new patient whom they’ve never laid eyes on before, they may feel less comfortable in making an assessment or a diagnosis of that patient.”
Drivers of Modality Selection
Patient preference was the largest factor (73.3%) in clinicians’ decision to choose video, phone, or in-person care, followed by clinical judgment (56.7%) and leadership guidance (30.7%). Primary care clinicians were more likely than other respondents to say that scheduling staff had a major impact on their decision. Mental health clinicians were more likely to report that leadership guidance affected their choices, along with evidence regarding the relative effectiveness of the modalities.
Specialists were more likely than primary care or mental health clinicians to endorse significant challenges of phone appointments, including the inability to assess physical status or conduct a physical exam and the inability to receive full workload credit. The study didn’t say — and Connolly couldn’t explain — why they had concerns about their employers giving them credit for phone appointments but not video visits.
Primary care clinicians and specialists saw more challenges in video appointments than mental health professionals did. Besides the inability to conduct adequate physical exams in video visits, these clinicians cited patient challenges, such as difficulty in using a video-enabled device or telehealth platform and inadequate internet connectivity.
In addition, Connolly noted, appointments are much shorter for primary care and specialty care providers than for mental health clinicians.
“Maybe they get 15 to 20 minutes with a patient, and their case loads are much bigger because of that. With a video appointment, maybe the patient has trouble connecting, maybe they haven’t used this app before, or they don’t know how to enable their microphone or their camera. If you have only 15 minutes, it’s challenging to think you’re going to give up some of those minutes to troubleshoot the tech.”
Some experts, she noted, have discussed the idea of “virtual rooming,” in which a medical assistant connects with the patient and performs the troubleshooting first, and the provider logs on only when the patient is ready.
Video vs Phone Encounters
Most clinicians preferred video over phone for conducting telehealth visits. Mental health clinicians showed the showed strongest preference for video encounters. This finding reinforces those of previous studies, the researchers say.
Mental health clinicians were also more influenced than were other respondents by data regarding the comparative effectiveness of the different modalities. There is strong evidence that video visits are noninferior to in-person visits for behavioral care, and there’s some evidence that phone visits aren’t as good as video visits, the authors note.
Speaking as a clinical psychologist, Connolly said video visits give mental health professionals more information than phone visits.
“We can see our patients’ facial expressions, we can see their home environment. Other providers care about this information, too. But in a few areas, mental health providers are different,” she noted. “For one thing, mental health appointments are typically longer than what we see in primary or specialty care. These visits can be as long as an hour and may be weekly or biweekly ― more frequent than in other specialties. So mental health providers may feel it’s worth it to put in the time for that video call, because they may have time to troubleshoot the call.”
Primary care clinicians and specialists were more likely than mental health providers to rate phone care as high as video visits. They also saw more problems with telehealth in general. Specialists were more likely than the other respondents to rate telehealth as inferior to in-person care for new patients. They also saw more challenges with phone visits than the primary care clinicians did. These are among the reasons why the specialists conducted the highest percentage of in-person visits.
Patient vs Clinician Preferences
Patients preferred video to phone visits, but a large portion of remote visits were conducted by phone, the authors say.
In another study cited by the researchers, one third of Medicare enrollees were offered only phone visits for remote appointments, although most of them owned video-enabled devices. This and other studies raise the question of whether it’s really patient preference, rather than clinician preference, that drives the choice of modalities, the authors note.
On the other hand, they add, the COVID-19 pandemic has revealed “a stark digital divide in which patients who are older and/or have lower income are less likely to be video-ready.” Thus, it’s important to increase patient access to video-enabled devices and broadband connectivity, they say.
JAMA Netw Open. Published online June 6, 2022. Full text
Ken Terry is a healthcare journalist and author. His latest book is “Physician-Led Healthcare Reform: A New Approach to Medicare for All.”