Telehealth’s Newest Safety Risk: Distracted Patients

Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company

Updated January 6, 2021: Without considering telephone medicine, telehealth has been part of the American healthcare landscape for more than 60 years. Although the Centers for Medicare and Medicaid Services began reimbursing for rural telehealth in 1999, by 2019 telehealth accounted for only 0.1 percent of Medicare fee-for-service (FFS) visits.¹ During COVID-19, federal and state telehealth regulatory and payment concessions led to an enormous surge in use. At the peak of the first surge of COVID-19 in April 2020, Medicare FFS telehealth had risen to 45.3 percent of all visits, roughly 1.25 million visits per week.

Sudden widespread adoption of telehealth during the pandemic allowed millions of patients to receive care that might not have otherwise been possible. Rapid adoption of telehealth permitted practices that provided a significant amount of elective procedure‒related care or outpatient demographics to remain afloat. Rapid implementation of telehealth services came with new challenges. For more information on that topic, please see The Doctors Company white paper Your Patient Is Logging on Now: The Risks and Benefits of Telehealth in the Future of Healthcare.

Our first inkling that a new risk may be appearing on the horizon came in the form of a helpline call from a primary care physician in California. The physician called to discuss the risk management of a problem he was experiencing with some of his virtual patients. It seemed the patients were not always ready for, or engaged in, the telehealth visits. The physician gave examples that included a patient excusing himself to take a cell phone call and another answering a knock at the door, shouting that his ride had arrived, and leaving without disconnecting from the video visit. Depending on your level of telehealth use, these examples may or may not be surprising.

In October 2020, a telehealth company published its results of a survey to determine consumers’ attitudes to telehealth and healthcare. The survey of 1,002 consumers identified a wide number of distracted patient behaviors during telehealth visits. Not surprisingly, digital distractions were the most frequently reported and included using the internet (24.5 percent), watching TV or movies (24 percent), checking social media (21 percent), and playing video games (19 percent). The more unusual distractions included exercising, smoking, eating, driving a motor vehicle, and consuming alcoholic beverages.² In addition to the distractions previously noted, members of The Doctors Company have reported patient behaviors that include no-shows, vacuuming during the visit, children sitting on the patient’s lap, and patients calling in from public venues such as a bus, airport, or café.

We know the effects that distracted doctoring can have on patient safety. (For more information about distracted practice, see our article “Distracting Devices in Healthcare: Malpractice Implications.”) The risks incurred when the patient is distracted are similar. They include lack of engagement resulting in a limited history and assessment process; nonadherence with the treatment plan, discharge instructions, or follow-up; and privacy and security concerns.

Distracted patient behaviors can limit the provider’s ability to establish rapport with the patient and collect the information necessary to accurately diagnose and treat the patient’s condition. Patient nonadherence is a known contributor to delayed diagnosis and, consequently, to medical professional liability. Privacy concerns involve the discussion of patient-specific health conditions within earshot of others—which may lead the provider to restrict the extent of the clinical discussion. Healthcare providers have limited control over the security of patient devices. Therefore, providers should consider putting additional security measures in place to reduce the risk of malware intrusion, particularly if the telehealth system is on the same network or integrated with the electronic health record.

Strategies to Address Distracted Patients

1. Set technology expectations for telehealth visits.
   Ask patients to connect to telehealth visits from a computer (rather than a mobile device) when possible.
   
   For patients who intend to use a phone, advise them to activate their phone’s Do Not Disturb feature and close any open apps.
   
   Some patients may have difficulty disconnecting from social media even during a health visit. Behavioral health experts have described this as “fear of missing out” (FoMO), a phenomenon considered to be a symptom of social media or digital addiction. Experts recommend encouraging patients to disconnect periodically to reduce the risk of FoMO.³ Patients who have difficulty disconnecting can be encouraged to use positive self-talk in FoMO situations. For example, instead of thinking “I am unable to answer that call/message/post,” advise the patient to consider “I do not need to answer that now.”⁴

2. Set behavioral expectations for telehealth visits.
   Advise patients to participate from a private location, preferably in their home.
   
   Ask the patient to be seated facing the computer in a well-lit space away from distractions, including family members and pets.
   
   Follow up on prior no-show visits if needed. Studies suggest that younger patients and those receiving surgical follow-up are less likely to present for telehealth visits. In addition to sending reminders, a face-to-face discussion of the risks of missed visits may reduce the likelihood of further occurrences.⁵

3. Assess the patient’s environment at the initiation of the visit and respond accordingly.
   Public spaces: Advise patients of the privacy risks of conducting a telehealth visit in a public space and offer to reschedule the visit.
   
   Driving: Ask patients who are driving to pull over. For patients who refuse, politely advise them that it is unsafe to continue the visit and they will be rescheduled, then disconnect. If the patient pulls over, discuss your concerns, and use your judgment about continuing with the visit.
   
   Smoking: If the patient is smoking, discuss smoking cessation.
   
   Drinking alcohol: If it appears that the patient is drinking alcohol, politely confirm and consider conducting a brief intervention using a tool such as Screening, Brief Intervention, and Referral to Treatment (SBIRT).

4. Document the interventions taken to address patient distraction.
   Document what you did, how the patient responded, and the result. If the plan is to reschedule the patient, ensure that the patient is rescheduled.

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