In the world of telehealth, business is booming. 

Although virtual medicine has been a possibility since the 1960s — when NASA scientists pioneered technology to monitor astronauts’ health during space missions — it’s an option that, pre-pandemic, was largely restricted by Medicare and Medicaid to patients living in rural areas with limited health care resources. 

Then along came COVID. Regulatory barriers lifted overnight, allowing clinicians to shift millions of in-person visits to digital platforms. Today, more patients and practitioners are using telehealth than ever before, a reality reflected in the stock market: The global telehealth industry, valued at $41 billion in 2019, will more than triple to reach $155 billion by 2027, according to market research firm Grand View Research. As Danielle Hartigan, associate professor of Health Studies and director of Bentley’s Health Thought Leadership Network (TLN), puts it, “Telehealth is here to stay.” 

The sudden shift from in-person to virtual visits is not without growing pains, however. As Hartigan notes, “Surprisingly little attention has been paid to the design and impact of digital environments.” As a result, “clinicians lack evidence-based guidance about how to effectively use video communication to enhance patient experience and outcomes.” Determined to fill that void, Hartigan enlisted a team of researchers — including colleagues from Dana-Farber Cancer Institute, fellow Bentley faculty members, and current and former students — to explore and define telehealth best practices.  

DIFFERENT BY DESIGN

Key among those collaborators was fellow Health TLN member Jon Ericson, assistant professor of Information Design and Corporate Communication and director of Bentley’s Immersphere, an on-campus lab devoted to virtual reality and other immersive technologies. A cognitive scientist specializing in human-computer interaction, Ericson has a keen understanding of the psychological, social and physiological differences between in-person and virtual settings. 

“We lose a lot of the depth and richness of sensory information in digital environments,” he notes. “Video communication, for example, converts our normal, three-dimensional view into a series of flat, two-dimensional images, reducing the nonverbal cues patients rely on to process information.” This makes it almost impossible to maintain direct eye contact, and easy to overlook micro-expressions and other subtle emotional cues, which clinicians use to assess patients’ mental health. 

Sounds are also affected. “When we speak to each other in person, we’re able to hear more frequencies and tonalities, which help to convey emotion,” Ericson explains. “In virtual environments, sounds become attenuated, creating variations in intensity levels that influence how information is received.” Poor camera resolution, awkward viewing angles, ambient features, and delays in internet bandwidth can also adversely affect conversations between patients and providers.  

REDEFINING CLINICAL COMMUNICATION

While the researchers found evidence of these limitations as they reviewed previously published studies related to social and environmental psychology and human-computer interaction, they also discovered surprising ways virtual visits can enhance the patient experience. 

“It was particularly interesting to learn how a shared digital space can shift the power dynamic between participants,” says Ja-Nae Duane ’23, a PhD in Business student and member of the research team. “In a traditional clinical setting, the provider has more perceived power. But in telehealth encounters, each participant occupies an equal amount of ‘space’ — a power shift that may increase a patient’s feeling of emotional empowerment and willingness to share information.”  

Even when patients aren’t particularly forthcoming, clinicians can gain valuable insights from observing the patient’s environment. “Seeing a patient’s dusty house and cats could be valuable information to have when treating an asthmatic with chronic obstructive pulmonary disease,” Hartigan notes. “Similarly, noticing a pill box that has medications from several days ago might explain why a patient with congestive heart failure is struggling to breathe.”  

FINE-TUNING FOR THE FUTURE

Ultimately, researchers discovered both benefits and drawbacks within current telehealth use. Their findings, which include a summary of best practices for clinicians to use in designing effective telehealth environments (see below), underscore the critical need for the health care industry to devote time and resources to continued research into virtual medicine and its emotional, cognitive and health-related outcomes.  

“Engaging clinicians in the thoughtful and systematic design of these environments is essential,” Hartigan stresses. The vast majority of health care organizations were unprepared for the sudden and unexpected shift to telehealth necessitated by COVID, she says, adapting on the fly. While adequate for the short term, “this type of training should not be an add-on or afterthought in clinical education.” 

With telehealth use only growing in prominence, it’s important for clinicians to understand how to successfully adapt their bedside manners to digital environments, Hartigan says. “The need for more intentionally designed environments that empower patients and improve health care outcomes has never been greater.” 

Professionalism Cues

Proximity to Camera

Spatial Distance Cues

Ambient Features (light, color,sound)