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Human Factors (HF) in Telehealth Implementation

Abhinav Goyal

School of Nursing, University of San Diego

HCI 559: – Management of Health Care System Quality Outcomes and Patient Safety

Dr. Brenda Boone

December 7, 2022
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Human Factors (HF) in Telehealth Implementation

The COVID-19 pandemic demonstrated the value of telehealth programs by enabling the

continuation of patient care at a time when in-person visits were challenging or impossible

(ECRI, 2022a). Telehealth is a broad term that includes a variety of remote health-related

services and information such as patient care, administrative activities, continuing medical

education, and/or provider training. Within patient care, telehealth encompasses a wide range of

activities such as virtual visits, remote vital sign monitoring, and store-and-forward imaging.

Telemedicine is the provision of clinical services (diagnosis and treatment of patients) using

telecommunications technology, which includes both video and telephone platforms (Perry et al,

2021; Shaver, 2022). According to Lo et al. (2022), telehealth visits have been a part of

some medical practices for some years and have been steadily increasing over the past

decade, but the COVID-19 epidemic and the related social distancing guidelines accelerated the

trend toward remote care. To combat the spread of COVID-19, several health practitioners

began to give more services remotely.

According to Shaver (2022), telemedicine has numerous benefits for patients and

healthcare practitioners, resulting in outcomes comparable to in-person care for some acute and

chronic conditions. Telehealth is expected to become increasingly widespread in future US

healthcare since it is well received by many consumers and healthcare practitioners. The usage

of telemedicine between doctors and patients has increased since the beginning of the COVID-

19 epidemic when in-person treatment was quickly replaced by remote consultation (Shaver,

2022). According to ECRI (2022a), several institutions and caregivers are already experiencing

the burden of relying on telehealth programs that were rushed into place during a crisis, with

little time to evaluate workflow and human factors (HF).

HF is the approach of designing a work system according to a user. It focuses on

developing different system components based on how humans think and behave, rather than

forcing humans to adapt their behavior to the system (Fouquet and Miranda, 2020). It is more
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vital than ever to use quality improvement science to ensure that telemedicine is safe, effective,

efficient, timely, person-centered, and equitable (Perry et al, 2021). HF and system design are

components of the framework for providing safe, equitable, and person-centered care via

telemedicine (Perry et al, 2021). According to ECRI (2022a), inaccurate or incomplete data can

result in poor treatment decisions, while large amounts of data might overburden the clinician.

Facilities must consider issues that might result in poor outcomes for patients (such as

misdiagnoses, delays in care), as well as for clinicians (e.g., cognitive overload, clinician

burnout), as they work to enhance telehealth care-delivery models for the long term (ECRI,

2022a). In the rush to implement telemedicine, it is critical not to lose sight of essential quality

concepts, as well as the specific risks, possibilities, and potential unintended effects of virtual

care (Perry et al, 2021).

The purpose of this paper is to take human aspects into account and suggest problem-

solving strategies to implement user-friendly, sustainable telehealth services into the health

system. In this paper, the literature on HF and telehealth programs will be reviewed with an

emphasis on the relevance of workflow and HF prior to telehealth adoption. HF issues that are a

threat to patient safety and can decrease patient quality outcomes will be addressed along with

possible solutions.

Literature Review

When looking for research articles and recent literature on HF design and safety

considerations for telemedicine, a PubMed search on articles published within the last 5 years

(2017 through 2022) was conducted using the following key terms: human factors, safety,

implementation, and telehealth. This initial search resulted in 14 total publications. After

implementing inclusion criteria for only full-text articles written in English, 2 articles by Fouquet &

Miranda, 2020 and Zhang et al., 2021 were selected. The paper by Alkureishi et al. (2021) was

considered because it highlights issues with physical examination, workflow, burnout, and a
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decreased level of connection with patients. The white paper by Perry et al. (2021) from the

Institute for Healthcare Improvement (IHI) was also reviewed.

Summary and Analysis

Alkureishi et al. (2021) performed a cross-sectional study at the University of Chicago

Medical Center to understand telemedicine advantages and limitations, workflow implications,

and training and support needs. The top three most cited barriers to conducting video visits by

the 200 pediatric and adult medicine clinicians were patient-related, including patient lack of

technical knowledge (n=139, 70%), limited patient access to necessary technology for a video

visit (n=132, 66%), and patient reluctance to have a video visit (n=75, 38%). The article

suggests training should focus on incorporating learners into workflows. Participants were also

asked to self-report their perceived level of burnout to assess clinician overload and satisfaction.

Overall, 81 clinicians reported burnout, with younger doctors reporting higher levels of stress. It

was observed that the clinicians who got additional video visit training modalities (for example, a

paper and webinar on technical concerns) were less likely to feel overwhelmed by video visits

(P=.02) or burnout (P=.001). Clinician training and patient telehealth access initiatives are

required to ensure the long-term sustainability of telehealth services (Alkureishi et al., 2021;

Shaver, 2022).

According to Perry et al (2021), culture and the learning system are the two components

that serve as the foundation for developing high quality safe systems. Health care institutions

must consider the technology infrastructure and other resources accessible to both the

organization and the community it serves, while designing a strategy to implement the telehealth

framework. Health care organizations must collaborate with community organizations (for

example, a trusted pharmacy, church, school, or community center) to provide community

knowledge, physical space (for example, to house telemedicine kiosks), technological

infrastructure, and assistance that can facilitate tele visits. See Appendix A for
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recommendations to improve HF and system design in telemedicine. An important HF aspect is

that both the patient and provider should be trained and comfortable to use telemedicine

technology and virtual care methods. Also, vital cues should not be overlooked when treatment

is delivered online as it may result in diagnostic mistakes and a loss of trust between the

clinician and the patient. Continuity of care and care coordination should be considered while

designing the telehealth services (Perry et al.,2021).

According to Zhang et al. (2021), there is considerable variation in telehealth education

and training, which results in varying degrees of clinician acceptance. Additionally, barriers like

technology access, connectivity, and navigation still prevent patients from having a higher level

of acceptance. Redesigning the telehealth system is essential to achieving improved levels of

user acceptability and satisfaction, both from patients and providers. See Appendix B for

assessment of barriers related to and impact of telehealth implementation during the COVID-19

pandemic. The workflow and work content of care providers have also been affected by current

telehealth practices, which has put a tremendous amount of stress on the healthcare system. 

One approach that enables providers to learn about the results of their care decisions and

ensure continuity of care is to set up routine tele follow-up communication.

Fouquet & Miranda (2020), states that providers and their institutional leadership should

consider the needs, capabilities, and environment of their end users (both patients and

providers) when implementing a telehealth service. Training staff and patients on system usage

and basic troubleshooting, as well as planning for frequent quality improvement efforts and

sustainability, will all fail if the system design has a fundamental issue. See Appendix C for key

points, and a sample of appropriate methods for telemedicine implementation. Every component

of the telehealth system should be user-centered, which may be achieved by conducting a

needs assessment that comprises interacting with end users and collecting survey responses to

evaluate limitations of end users (i.e., socioeconomic disparities). Testing phase is crucial
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before implementation. Benchmark testing, user testing, heuristic analysis, failure modes and

effects analysis (FMEA) should be conducted to determine feasibility, to evaluate EHR

system and patient portal integration and to assess vendors. While brief testing may not

uncover all the limitations and hurdles, it can highlight important HF and system issues.

Conclusion

According to ECRI (2022b), lack of HF consideration during telehealth system design,

development, usability testing, and assessment might lead to several issues for patients and

providers, including fragmented adoption, disrupted workflow, user discontent, and even system

failure. Furthermore, stakeholders and system user issues were identified as the primary barrier

(79%) on implementation and integration problems in telehealth. Alkureishi et al. (2021)

emphasizes on clinician training as one solution, Perry et al (2021) indicates increasing

community knowledge and technology access via community collaboration, Fouquet & Miranda

(2020) highlights user assessment, testing, education and training and Zhang et al. (2021)

states telehealth education and training among clinicians can be a solution. The literature for

each article reviewed emphasizes key stakeholder involvement (patients, families, and

caregivers) early in the design process to create a user-centered system design as the primary

solution to HF and telehealth implementation.

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Identified Solution

The literature review indicates that telehealth-mediated health care system should be

based on users’ needs and experiences. In addition to addressing system design issues like

privacy or access concerns, language barrier, technology literacy, and usage difficulty, the

practice of co-designing and co-producing care with key stakeholders (patients, families, and

care providers) will also help in building trust and fostering connections (Fouquet &

Miranda,2021; Perry et al ,2021; Zhang et al., 2021).

Consideration of user experiences from all stakeholders is essential for successful

telehealth service implementation, optimization, and sustainability (ECRI 2022b; Fouquet and

Miranda, 2020). Rather than adding telemedicine technology on top of existing systems, health

systems should completely integrate telemedicine into the system to ensure that it is secure,

and truly tailored to the requirements of stakeholders (Perry et al, 2021). To find out what issues

patients and clinicians are having with already-in-place telehealth services, user feedback

should be collected. According to Zhang et al. (2021), patients have more responsibility with

telehealth and fill systemic gaps such as navigating an unfamiliar method of accessing care,

filing in verbal description of symptoms to care providers, and recording their own vital signs

prior to video consultation. An electronic user guide with clear, cohesive, and non-technical

language should be provided. Appropriate training can be given to end users to help solve minor

issues such as workplace distractions, such as noise and lighting (Zhang et al., 2021).

Because a patient's health and medical circumstances are dynamic, the care offered

must be dynamic as well to fulfill the patient's demands. As a result, patient and family

representatives must be included as participants in the co-design of telehealth services (Perry et

al, 2021). Future initiatives should address these implementation barriers by redesigning

telehealth programs in a structured way so that health care systems can minimize the negative

effects of telehealth and deliver telehealth services safely (Zhang et al., 2021).
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References

Alkureishi, M. A., Choo, Z.-Y., Lenti, G., Castaneda, J., Zhu, M., Nunes, K., Weyer, G., Oyler, J.,

Shah, S., & Lee, W. W. (2021). Clinician Perspectives on Telemedicine: Observational

Cross-sectional Study. JMIR Human Factors, 8(3), e29690.

https://doi.org/10.2196/29690

ECRI (2022a, January). Telehealth Workflow and Human Factors Shortcomings Can Cause

Poor Outcomes. Evaluations & Guidance.

https://www.ecri.org.uk/wp-content/uploads/2022/05/ECRI_2022_Top_10_Hazards_Exe

cutive_Brief.pdf

ECRI. (2022b, March 11). Human Factors in Operationalizing Telehealth. Health System Risk

Management. https://thewellnews.com/wp-content/uploads/2022/03/ECRI-Top-10-

Patient-Safety-Concerns-2022-Special-Report-1.pdf

Fouquet, S. D., & Miranda, A. T. (2020). Asking the Right Questions—Human Factors

Considerations for Telemedicine Design. Current Allergy and Asthma Reports, 20(11),

66. https://doi.org/10.1007/s11882-020-00965-x

Lo, J., Rae, M., Amin, K., & Cox, C. (2022, February 10). Outpatient telehealth use soared early

in the COVID-19 pandemic but has since receded. Peterson-KFF Health System

Tracker. https://www.healthsystemtracker.org/brief/outpatient-telehealth-use-soared-

early-in-the-covid-19-pandemic-but-has-since-receded/

Perry A.F., Federico F., Huebner J. (2021) Telemedicine: Ensuring Safe, Equitable, Person-

Centered Virtual Care. IHI - Institute for Healthcare Improvement.

https://www.ihi.org:443/resources/Pages/IHIWhitePapers/telemedicine-safe-equitable-

person-centered-virtual-care.aspx

Shaver, J. (2022). The State of Telehealth Before and After the COVID-19 Pandemic. Primary

Care: Clinics in Office Practice. https://doi.org/10.1016/j.pop.2022.04.002

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Zhang, T., Mosier, J., & Subbian, V. (2021). Identifying Barriers to and Opportunities for

Telehealth Implementation Amidst the COVID-19 Pandemic by Using a Human Factors

Approach: A Leap Into the Future of Health Care Delivery? JMIR Human Factors, 8(2),

e24860. https://doi.org/10.2196/24860
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Appendix A

Recommendations to Improve Human Factors and System Design in Telemedicine

Note. Adapted from “Recommendations to Improve Human Factors and System Design in
Telemedicine,” by IHI Team 2022, Telemedicine: Ensuring Safe, Equitable, Person-Centered
Virtual Care, (https://www.ihi.org/communities/blogs/recommendations-to-improve-human-
factors-and-system-design-in-telemedicine)
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Appendix B

Table. 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 & components Impact Issues

Telehealth-enabled work system
Person as patients Increased acceptance of Insufficient and variable levels of
telehealth due to convenience digital literacy among the patient
population

Widening of health care disparities

Person as providers Increased motivation Mental or physical challenges due
to the imperative and wide adoption
Alleviation of workforce shortage of telehealth
due to the quarantine
Technologies and Enhanced patient and health care Telehealth may be disruptive and
tools worker safety not user-friendly

Conserve PPE
Environment Highlighted the suboptimal and
complex environment for
telehealth uptake
Tasks for patients Safer and potentially quicker
access to care
Tasks for providers Clinical and nonclinical services
can be safely continued via
telehealth
Organization Formulation of new teams
Insufficient communication
infrastructure
The environment where patients
interact with telehealth technology
may be suboptimal
Systemic, informational, procedural
gap that patients need to fill in
Challenges in adapting to changes
in job content and demands
Dynamic changes to teamwork

Maximizing the utilization of Reallocation of accountability and

existing resources to deal with
the pandemic
Telehealth-enabled processes
Care Processes Wide application of forward-
responsibility
Redistribution of labor, equipment,
information, and funding resources
Time management is more

Domain & components Impact
triage, tele-intake, and tele-ICU
Increase in web-based visits
replacing in-person visits and
mixed processes (i.e., some in-
person visits and some tele-
visits)
Other processes Reduced demand of other
processes that support care
processes (e.g., reduced
environment disinfection needs
due to the fewer in-person visits)
Telehealth outcomes
Patients’ outcomes Unclear
Care providers’ and Unclear
organizational
outcomes
Note. Table adapted from “Identifying Barriers to and Opportunities for Telehealth
Implementation Amidst the COVID-19 Pandemic by Using a Human Factors Approach: A Leap
Into the Future of Health Care Delivery,” by Zhang et al., 2021 JMIR Human Factors, 8(2),
e24860., (https://doi.org/10.2196/24860)
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Issues
challenging (e.g., 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
Information flow may be more
fragmented
Lack of measures for patient safety
and quality of care evaluation
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
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Appendix C

Key points, and a sample of appropriate methods for telemedicine implementation.

Note. Infographic used from “Asking the Right Questions—Human Factors Considerations for
Telemedicine Design,” by Fouquet, S. D., & Miranda, A. T. ,2020, TELEMEDICINE AND
TECHNOLOGY, (https://doi.org/10.1007/s11882-020-00965-x)