Challenges and recommendations in the implementation of audiovisual telemedicine communication: a systematic review
Article information
Abstract
This systematic review aims to identify the elements of doctor-patient communication in telemedicine, emerging challenges, and proposed recommendations. Four databases, including Science Direct, PubMed, Cochrane, and ProQuest, were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria consisted of original research papers, availability of free full text, and publications during the past 10 years. A total of 13 articles completed the selection process and satisfied the established criteria. The issues and recommendations of telemedicine communication were categorized into three distinct groups: pre-consultation, during-consultation, and post-consultation. Preparation encompasses the arranging of visual elements, safeguarding patient privacy and confidentiality, and addressing any technical challenges that may arise. The consultation encompasses nonverbal behavior, empathy, the doctor-patient connection, and a physical examination. Post-telemedicine consultations refer to medical appointments that occur after a telemedicine session, typically involving follow-up medical interactions. Telemedicine presents unique challenges in doctor-patient consultations that differ from face-to-face interactions. Therefore, clinicians must acquire communication skills specific to telemedicine to ensure effective consultations and achieve optimal health results.
Introduction
Telemedicine continues to play an important role in clinical medicine following the coronavirus disease 2019 pandemic [1]. Experts now consider telemedicine consultations a valuable and beneficial form of media for addressing most common health concerns [2]. Beyond its high utilitarian value, pre-pandemic studies also reported high levels of patient satisfaction [3-5]. Recent research shows that telemedicine provides long-distance specialist care, which is especially useful for those living in rural areas; minimizes hospital visits for vulnerable populations, such as children and the elderly; makes health care more accessible for patients who have trouble traveling to the hospital; and reduces travel time and costs [6-8]. Telemedicine currently widely serves various treatment needs and follow-up, including monitoring chronic conditions, delivering prompt information, administering medication, tracking laboratory test results, conducting radiology tests, scheduling appointments online, handling repeat prescription requests, and facilitating other routine treatments [9,10].
Despite its apparent benefits, communication in telemedicine may be more difficult than typical in-person consultations. Communication is an important aspect that affects health service quality, patient satisfaction, patient health outcomes, and doctor-patient relationships [11,12]. Doctor-patient communication plays an essential role in decision-making, exchanging information, improving the doctor-patient relationship, handling patient doubts, dealing with emotions, and improving self-management [13]. Good communication helps patients feel more confident in their medical professionals and, as a result, improves their overall satisfaction. Patients feel they are receiving better care when there is trust between them and their physicians [14]. Insufficient communication makes it more difficult to establish a doctor-patient relationship via telemedicine. Previous research found that patients felt less engaged in telemedicine consultations compared to in-person meetings [3,15]. In fact, it is estimated that only 7% of emotional communication occurs verbally, while 22% is communicated through tone of voice and 55% through body posture, gaze, and eye contact. These more subtle aspects apparently pose some challenges via telemedicine because the patient and physician are not actually meeting face-to-face but in a virtual “real-time.” Meanwhile, compared to actually consulting in the same room, the dynamics observed in a video consultation can be very different from the traditional in-person consultation [16].
The quality of telemedicine communication is different from that of in-person meetings because some communication elements cannot be applied or have limited application. Additional challenges exist in conducting certain communication components through telemedicine, such as the constraints on interpreting non-verbal behavior [17]. Previous studies showed that telemedicine consultations had less empathy, praise, and support than in-person consultations [18,19]. Non-verbal communications including body language and eye contact are prone to misperception in telemedicine consultations, even though these aspects are important in doctor-patient interactions, especially in building trust in the consultation relationship. In telemedicine doctor-patient communication, the effect of using body language can be significantly reduced or even lost. For example, patients may use non-verbal gestures that show a lack of understanding or disapproval [20].
Telemedicine communication differs from in-person communication. Hence, doctors need to comprehend the appropriate manner of communication, given the importance of effective communication in a medical consultation. Current studies on patient-doctor communication in telemedicine are still partial, they only discuss parts of elements of communication, such as only discussing non-verbal aspects, gestures, or technology [21-23]. Therefore, research on the overall communication between doctors and patients in telemedicine is needed. The goals for this systematic review are to (1) identify elements in doctor-patient communication in telemedicine; (2) find challenges that arise in doctorpatient communication in telemedicine; and (3) propose recommendations that can be applied to anticipate challenges that arise in telemedicine communication.
Methods
This systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify the elements of doctor-patient communication in telemedicine and emerging challenges with proposed recommendations [24]. Searches were performed on PubMed, Science Direct, Cochrane, and ProQuest databases. The keywords used in the search using PICO (Population, Intervention, Comparison, and Outcome) are P=“Doctor telemedicine” OR “Physician telemedicine,” I=“Communication doctor-patient in telemedicine” OR “Teleconsultation” OR “Communication skill doctor-patient in telemedicine”, OR “Video Consultation”, C=none, O= “Element communication skill doctor-patient in telemedicine” OR “Factor communication doctor-patient in telemedicine” OR “Basic communication doctor-patients in telemedicine”.
The inclusion criteria include articles published in the last 10 years, using the English language, and relevant articles with full text available. Articles that met these criteria were then thoroughly read and studied to see if they contained a discussion of the challenges and recommendations for telemedicine communication. The articles included in this review were only original research articles. Other articles, such as commentaries, reports, and editorials, were excluded. Articles that met the criteria were then analyzed in depth, and any findings related to challenges and recommendations were collected and tabulated for discussion. Table 1 shows the inclusion and exclusion criteria applied in this study. The article selection process for this study is shown in the PRISMA diagram in Fig. 1.
Inclusion and Exclusion Criteria
PRISMA Flow Diagram in this Study
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PICO: Population, Intervention, Comparison, and Outcome.
Results
Based on the systematic review conducted, 13 articles were selected that met the objectives of the research. The details of the studies included in this review are available in Table 2 [21-23,25-34]. After conducting an in-depth analysis of the 13 selected articles, the challenges and recommendations in telemedicine communication were grouped into three categories: preparation for the consultation, during the consultation, and after the consultation. Preparation includes visual setup, patient privacy and confidentiality data, and technical difficulties. During the consultation includes nonverbal behavior, empathy, the doctor-patient relationship, and physical examination. Finally, post-telemedicine consultations include follow-up medical encounters. The findings of this systematic review can be seen in Table 3.
Details of the Studies Included in this Systematic Review
Findings of Elements, Challenges, and Recommendations of Doctor-Patient Communication in Telemedicine Consultation
Discussion
Communication is an important factor in improving the quality of telemedicine consultations so that they can be complementary with to in-person consultations. Telemedicine has high user satisfaction due to its ease, affordability, efficiency, cost, and distance. The inability to conduct direct physical examinations, loss of nonverbal contact, and the emergence of privacy and confidentiality issues were found to be the main obstacles in telemedicine consultations [31]. This systematic review found that some communication components that cannot be done using telemedicine can be implemented differently, such as non-verbal behavior, which needs to be verbalized and emphasized with more direct expressions of empathy. Eye contact is especially important to express attention and check patient responses. Various issues arise because of this technology, such as concerns regarding privacy and confidentiality of patient data, in addition to barriers due to network problems, and patients not understanding technology. In providing ideal telemedicine services for patients, more preparation is required than those in face-to-face meetings.
1. Preparation before conducting telemedicine consultation
Telemedicine consultation is different from face-toface consultation in its implementation, so more preparation is needed. Visual appearance is very important because it determines the quality of communication that will be established. For this reason, attention to simple things such as camera setup, lighting, background, and appearance needs to be considered [21,22,26]. The facial expressions of doctors and patients are also important factors in medical consultations. Through expressions, doctors can find out whether the patient understands the doctor’s explanation or even determine the patient’s disease condition. Meanwhile, patients can tell whether the doctor is listening to them well [21]. In telemedicine meetings, facial expressions sometimes do not appear clearly on the screen due to various factors such as camera quality and poor lighting, so that the doctor’s or patient’s face is dark or covered in shadow.
Even though the use of telemedicine makes it easier for most patients to consult a physician, it has given doctors various new tasks and roles. These include additional patient setup (making sure the technology functions and assisting patients with its use), troubleshooting sources of problems with information technology (IT), having IT support and solutions, determining whether a patient is suitable for a virtual consultation, finding an appropriate physical space for “private” video interactions outside of clinic hours, and developing new forms of medical documentation while adjusting to the different ways in which electronic and paper documents and other artifacts were used in consultations [23]. Accordingly, an administrative role is frequently required to facilitate the implementation of telemedicine by physicians [28]. However, the presence of an administrator might also become a problem, since some patients may feel discomfort having other individuals participate in the consultation due to a lack of privacy. Thus, the amount to which the administrative position can facilitate the telemedicine consultation process will depend on the judgment of the physician and the actual patient’s unique circumstances.
Patients expressed concerns that there may be other people around the doctor who can hear the consultation, which can become another challenge of telemedicine service. Telemedicine consultations are vulnerable to information leaks, making the patients concerned that their personal data may be shared without regard to their privacy [22,29,30]. For this reason, consultation in a private environment and confirmation of data confidentiality are an absolute “must-do” [28]. The doctor needs to introduce anyone who can hear the consultation (usually the nurse) and ask whether there are other people around the patient who can hear this conversation [27]. If the patient is accompanied by other people, it is imperative for doctors to carefully consider their word choices in case there is a discussion that is sensitive and should be kept private from other people, such as in the case of an infectious disease or terminal illness. In contrast, another finding showed that telemedicine patients feel safer than in-person consultations. Patients perceived that remote consultations make them more anonymous and less exposed, so they can convey information that they think is sensitive [35].
2. During telemedicine consultation
The main obstacle during telemedicine consultations is the loss of the nonverbal aspect of the consultation. Telemedicine services are conducted with more verbal communication than nonverbal due to lack of physical presence, causing decreased nonverbal behavior. In addition, the use of long-distance nonverbal cues is prone to misperception of the doctor’s behavior; for example, when the doctor turns to take a file, it will be considered an act of neglect. To avoid this dilemma, a recent study conducted by Shaw et al. [27] stated that all activities carried out by doctors need to be conveyed and explained as simply as possible, such as “If I go silent, I’m writing. Okay?” Eye contact can also become a problem in telemedicine consultation. The doctor may see the patient’s eyes on the screen, but if the patient cannot, then this can be perceived as a form of loss of eye contact because it does not appear as if they are looking at the patient, making them feel ignored. In this case, the study conducted by Helou et al. [33] recommended that looking at the camera during explanations and checking the screen periodically could help to resolve or alleviate this situation. In contrast, telemedicine consultations had a positive effect on doctors by enabling them to monitor and correct their expressions in response to the patient’s story [21].
Building relationships in telemedicine consultations requires special attention because they are more difficult to form than in-person visits. Conveying empathy in telemedicine is more challenging because doctors cannot use supportive non-verbal cues, and patients also have difficulty interpreting the empathy given by doctors, thereby reducing engagement. According to Elliott et al. [21], conveying empathy can be done in the simplest form by providing silent time and letting the patient tell their story until they are satisfied. Listening to the patient’s story without interruption can also demonstrate a deeper and more sincere empathy for the patient. Additionally, the study of Gordon et al. [26] recommends building a doctor-patient relationship in telemedicine by encouraging patients to convey their personal opinions, which are solicited through patient-centered questions and more “personalized” treatment.
Telemedicine consultations limit physical contact between doctors and patients, making physical examinations difficult. Research by Gordon et al. [26] found that patients were worried that the physical examination was deficient even though they had received guidance from a doctor online. However, doctors can alleviate patient anxiety and maintain trust by clearly communicating their assessments, seeking assistance from onsite staff, or referring patients for in-person exams when necessary. Additionally, patients’ perceptions may evolve as advancements in telehealth technology enhance the capability to perform physical exams during telemedicine.
3. Post telemedicine consultation
After a telemedicine consultation, the patient may not know when to have another check-up. Therefore, followup is needed to remind patients about the next scheduled visit. Telemedicine consultations should be applied to repeat patients and only need a follow-up consultation, not to establish a new diagnosis. Thus, education and reminders for follow-up control are very important so that patients continue making medical visits.
Virtual consultations were most effective for managing long-term conditions where there was a strong, trustbased relationship between clinician and patient, no need for interdepartmental coordination, and when physical examinations were not necessary. They were particularly beneficial when there were clear advantages to virtual meetings, such as a history of missed in-person appointments or difficulties with patient travel. Both the clinician and patient needed to be confident and competent with the technology, and frequent contact was required. In these ideal situations, video consultations were found to be safe and well-received by both patients and staff, with patients especially appreciating the convenience and the ability to avoid taking time off work [23].
Furthermore, it was found that telemedicine consultations were more suitable for control patients who are already undergoing treatment, such as patients with hypertension and diabetes, since the majority of these patients often do not necessitate a physical examination that would provide support for the follow-up consultation. Research revealed that telemedicine consultations had a shorter duration compared to in-person consultations, potentially due to the prevalence of repeat patients among telemedicine users. Nevertheless, patients with severe conditions or those requiring medical procedures or physical examinations, such as antenatal consultations, cannot be seen via telemedicine [23].
Conclusion
In conclusion, although the implementation of telemedicine is very beneficial for patients, there are still some communication barriers that can affect the quality of consultations. To deal with these emerging obstacles, several practical solutions can be applied, and more preparation is needed in telemedicine consultations. Some limitations of the research are that it only selected articles from the last 10 years, even though telemedicine services have been conducted at the global level for several decades. In addition, technological advances are accelerating telemedicine research, so while this manuscript was written and submitted, there may now be more telemedicine research that is relevant to this study. Our search was also limited to virtual doctor-patient communication, even though virtual communication has very broad uses. If further research is conducted in other fields such as tele-nursing and palliative care, communication components may be found that can be applied to improve telemedicine communication capabilities. While the use of telemedicine is predicted to continue to increase, telemedicine communication is still not widely studied and taught to medical students; therefore, learning the specific challenges and recommendations about telemedicine communication for medical students needs to be done to equip them with good communication skills in conducting telemedicine consultations.
Acknowledgements
The authors would like to thank Septiana Purwandini as research assistant for helpful preparation during the research.
Notes
Funding
None.
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Author contributions
Conception or design of the work: IR. Data collection: IR. Data analysis and interpretation: IR, MR. Drafting the article: IR, MR, SW. Supervision: MR, SW, HS. Review and editing: MR, SW, HS. Final approval of the version to be published: all authors.