Telemedicine and Trust

Telemedicine is no doubt the future of healthcare. But just how exactly will that future pan out? Imagining the future of telemedicine through the lens of the present does not reflect an accurate trajectory of where telemedicine will be.

Instead of looking at current technological trends, look at the perception of patient using telemedicine – specifically how they trust the platform – to discern the future of telemedicine.

An early indication of how most patients perceive telemedicine can be seen in the behavior among patients struggling with substance use disorder and with fears of the coronavirus. Telemedicine provides a venue to alleviate immediate concerns – the in the moment existential angst – that if not addressed in its early onset, can manifest into unnecessary emergency room visits or more explicit acute psychiatric conditions such as anxiety.

Originally, many patients with chronic care conditions, and substance use disorders, used telemedicine to address psychiatric symptoms that arose alongside their primary conditions. During the pandemic, scores of patients rushed online to express their fears – but not just about their symptoms, or perceived risk of being infected – but about their jobs, livelihood, and other issues not traditionally associated with medical care.

But in that moment of fear, those issues became medical issues. And telemedicine became the platform to express that fear. Telemedicine builds trust as much as it treats conditions, and for many patients who use the platform for urgent needs, trust and treatment are essentially the same. A point emphasized by Malcolm Gladwell who believes trust exists as a reciprocal relationship with communication.

Dementia among the elderly is a prime example of trust and communication. Dementia is a progressive disease influenced by a patient’s social interactions, emotional well-being, and genetic predisposition all related in a complex balance. Behavioral isolation, a condition evangelized by former surgeon general Dr. Vivek Murthy, was previously seen as an effect, as a symptom of dementia.

But by understanding the relationship between everyday behavior and worsening existing symptoms, Dr. Murthy is highlighting the relationship between behavioral isolation and dementia progression. Loneliness has a complex relationship with dementia, as one affects the other, so rather than distinguishing one from the other, we should study the relationship between the two.

And in studying relationships rather than studying distinctions between behaviors and conditions, we observe gaps in care that telemedicine wil fill.

During a traditional patient encounter, what we observe is just a snapshot of the entire clinical presentation, which changes depending upon the perception of the patient in different moments of time and how comfortable the patient feels communicating with the provider. The relationship between the patient and provider affects the quality of the encounter for more than the actual clinical decision made.

Telemedicine can optimize the subjectivity that exists in patient care by providing more points of engagement. And by providing more points of engagement, patients can express more subjective aspects of their medical conditions – the aspects that subtly underlie decisions to remain compliant or maintain adherence even under unfavorable circumstances.

Prospect Theory, a behavioral model developed by Daniel Kahneman and Amos Tversky, integrates emotions into decision-making by adjusting the probability of outcomes with decision weights, that incorporate subjective metrics like perceptions of loss that dictate decision-making into the outcomes.

During the coronavirus pandemic, many of the mortality projections needed to be adjusted relatively frequently, mostly because they failed to account for unforeseen behavioral responses by people represented in the model. Behavioral responses that are emotionally derived, based upon the interpretations of the events transpiring around them – demonstrating the importance of these subjective metrics at a larger level.

But at an individual level, telemedicine can provide the ongoing communication necessary to glean changes in patient behavior that arise from perception changes.

Healthcare models should integrate telemedicine as a complementary tool to focus on the subjective aspects of patient behavior that adversely impact patient behavior. For example, a patient may perceive her hypertension to be inconsequential to her overall health, but after experiencing a hypertensive crisis requiring an emergency visit to the hospital, she perceives her condition to be serious and changes her lifestyle to account for that change in behavior. That behavioral change is a reaction to an existing frame of reference that can be reinforced with ongoing telemedicine visits.

Healthcare is dynamic and complex, in state of perpetual interpretive flux. Healthcare systems that attempt to improve patient behavior without understanding the proper context of the underlying behavior, attempt to frame a decision model like a randomized clinical study. And will inevitably be limited in their success.

Unlike clinical studies, decisions are not made in sterile environments, and we should begin to explore models that utilize ongoing telemedicine visits as a complementary point of patient engagement to study changes in patient perceptions that influence healthcare behavior.

Patient perceptions are a complex concept, with a wide-ranging often unforeseen impact on patient care and outcomes. Changing perceptions affect patient behavior and can prompt clinically meaning reactions leading to a shift in decision-making. That we would miss in our traditional form of interval patient visits separated over week or months of time.

A study conducted by Pews Research Center found that 7/10 people thought trust was decreasing in the corporate world, but only 4/10 felt it was a problem – demonstrating an interesting shift in the perception of trust.

Trust in major institutions are giving way to trust in our own judgments and experiences. And this changing trend of trust affects not just the outlook for policymakers but for the outlook of telemedicine in the future of healthcare.

Patients are relying less on physicians as the absolute authority for their healthcare decision-making and turning to alternative sources – be it the internet or other mediums – to learn about their health. The result is a shift in trust away from one centralized source – the physician – and towards a whole host of alternatives.

Telemedicine can address the trust deficit that will arise among patients at this shift becomes more pronounced. And in the fast pace world of healthcare, that seems to only be moving faster, patients are overwhelmingly making decisions based upon their current perceptions and beliefs – and what they read the most, they trust the most.

The future of telemedicine is intimately tied to the changing trends in trust within healthcare. To predict how telemedicine will be used, study how patients trust their providers relative to other sources of healthcare information – that trend will portend the future of telemedicine.

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