Telehealth & Behavioral Science during COVID-19: An Interview with Dr. Hayden Bosworth

Caitlin Sullivan, BS and Allison A. Lewinski, PhD, MPH^✉; Integrated Primary Care SIG

The current pandemic remarkably impacted face-to-face health care delivery with the exponential increase and upward shift to telehealth and other virtual care modalities. These changes have strengthened access to health care resources, and the ability to engage in health and wellness practices. Telehealth holds tremendous promise for maintaining and/or increasing access to health care during and after the pandemic. Yet, considerations exist to ensure that the exponential growth of telehealth does not result in unintended consequences or to widen health inequities. We interviewed Dr. Hayden Bosworth to hear expert advice for behavioral scientists interested in telehealth research and to learn more about use of telehealth to improve health outcomes. We are interested in telehealth and are members of the Improving Access through Virtual Care Focused Area of Research at the Durham Center of Innovation to Accelerate Discovery and Practice Transformation.

Who is Hayden Bosworth, PhD?

I am a health services researcher and Professor of Population Health Sciences at Duke University Medical Center as well as the Deputy Director of the Durham Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham Veterans Affairs Medical Center. My research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) implementation research to eliminate health care disparities. I lead and collaborate on telehealth research in health systems both nationally and internationally.
 

What current challenges are we facing in regards to telehealth and the COVID-19 pandemic?

We have seen dramatic increases in the uptake and adoption of telehealth. We went from one extreme of not fully and adequately using telehealth prior to the pandemic to using telehealth as much as possible when the pandemic started. For instance, I’m aware of how one healthcare system increased their use of telehealth by 5x (times) in April, and that growth is probably not unusual for other systems. We need to remember that while telehealth is one tool that can improve outcomes, we cannot use the same hammer for every problem, in every situation, or with every patient. It is too early to know all the unintended consequences of rapidly shifting to telehealth during the pandemic. Future data will demonstrate whether we misdiagnosed, misused, or mistreated conditions during this rapid shift to telehealth from face-to-face encounters.
 

What concerns exist in increasing telehealth use during COVID-19?

Telehealth is not appropriate for everyone and for all circumstances. The pandemic highlighted unequal access to, and use of, telehealth in several populations. We need to ensure that we do not increase disparities by rushing to, and relying solely on, telehealth during times of crisis. When thinking about telehealth use, we need to consider the individual’s preferences as well as socioeconomic status, age, and rurality. Individuals who have a difficult time accessing or figuring out telehealth will be at a significant disadvantage. These individuals may not trust telehealth and/or not know how to use it and may delay necessary treatment due to these challenges and not be appropriately treated. We need to remember that technology does not work for everyone, and different diseases may require adaptation of our telehealth models.
 

What has been an unexpected challenge working in telehealth prior to COVID-19?

Over my career, I’ve experienced two challenges designing telehealth research and programs. These challenges highlight how multidisciplinary collaborations are important as we work to integrate telehealth more fully into our health care delivery systems.

Reimbursement, rules, and regulations. Historically thinking about health care—telehealth delivery was primarily limited by reimbursement. Telehealth was difficult to sustain or implement because reimbursement was not aligned with the use of telehealth and legal issues impeded uptake. Fewer barriers to telehealth currently exist due to changes in care delivery and reimbursement policies around COVID-19. Now, telehealth aligns more with financial models—the rules and regulations are changing in a good way. Hopefully after COVID-19, we will continue to see alignment of reimbursement to increase the use and uptake of telehealth.

Disconnection between developing a telehealth program and deploying the program. Practical issues exist when using telehealth, and individuals may experience distress and anxiety when using telehealth in place of face-to-face appointments. I have heard these concerns over the years in my own research and seen these concerns play out in in my own family. How does someone who is not experienced with, or exposed to, technology figure out how to work these tools? Do individuals have a stable Internet connection? Do they have the right technological tools? Do they know how to use these tools? So, it is important to consider the patient’s familiarity with technology as well as other factors.
 

How can behavioral scientists prepare to examine telehealth use and uptake during and after COVID-19?

Behavioral science informs telehealth use, uptake, and adaptation. Behavioral scientists should have a knowledge base with an understanding of different behavioral theories, frameworks, and models that explain behavior change as well as knowledge of different study methods to evaluate interventions. We are in an applied field—so we need to ask the right questions first and then consider the study design or technology. If you start with the newest technology or shiny new object, you may fail to implement your research in the real world because it is impractical and inefficient. First, start with the behaviors you want to change, which will lead to an appropriate research question and design. Telehealth or the technology may or may not be a component. That is ok because if you expect telehealth to solve every problem that’s where you can get into trouble. Second, make sure the intervention is contextually appropriate for the right type of patient. Third, remember not all studies need to have a quantitative outcome or be randomized controlled trials. Be flexible and continue to learn about theories, methods, and study designs.
 

What should behavioral scientists consider when using telehealth to improve health outcomes?

We need to realize that everything in health care does not have to be via telehealth. The goal is to match and align the individual patient with the appropriate clinician or clinical service and telehealth modality. Focus on developing theory-based content and less on the technological device itself. Your content should stay constant, and good content can work across technologies. By creating the content first, and then determining the modality for delivering the content you can find the sweet spot of how to use telehealth appropriately for your population.
 

Any final thoughts?

The idea that one tool is going to fit for everyone will ultimately leave some behind. Instead of using one hammer, such as telehealth, we need to make use of our entire toolbox to figure out how to engage individuals across diverse populations, and if we can do it properly, we can help reduce health inequities. Technology will continue to change rapidly, so it all comes back to behavior and matching the technology to the needs of the individual. It’s a great time to work in telehealth and improve health outcomes in the real-world.