Telehealth Adoption and COVID-19

When COVID-19 hit the United States in early 2020, telehealth adoption surged as in-person healthcare visits became riskier.

Researchers estimate that some form of telehealth was used in more than 20% of all US medical visits in 2020, with the number of Americans who participated in at least one virtual visit jumping up nearly 60%. But as we look forward to a post-pandemic future, will this expansion of telehealth continue or will we all revert back to our old habits?

Telehealth before the COVID-19 pandemic

Telehealth has been around for the last three decades, but before COVID-19, 86% of Americans had never done a virtual visit. In the earlier decades, there were high equipment costs and many friction-causing regulatory/third-party requirements. Virtual visits tended to be a solution for underserved communities like those in rural areas or the prison system where standard in-person care was harder logistically.

During the last decade, though, technological advancements made telehealth increasingly available at a retail level. The number of physicians who offered telehealth was rising 20% year over year from 2015 to 2018. Yet, as mentioned, only 14% of Americans had ever done a virtual care visit before the pandemic.

While some healthcare innovations spread easily, telehealth was not among them. It was at best an afterthought in the larger picture of healthcare. Now, though, with the world completely changed by a pandemic, telehealth has found its footing, with many institutions realizing its benefits.

But what happens when the pandemic subsides? Will the situational factors that have spurred telehealth’s growth be able to sustain it in a post-COVID world?

Let’s look at telehealth adoption through the lens of Dr. Everett Rogers’ Diffusion of Innovations Theory and see what that tells us about what’s coming and what it will take to keep the beneficial changes in behavior that are occuring due to the pandemic.

Factors that influence technology adoption

Rogers’ Diffusion of Innovation Theory identifies five factors that influence the rate of adoption of an innovation. They clarify what it was about the pandemic that enabled telehealth adoption to grow. They can also help us understand what to expect after the pandemic. Of particular interest now, though, is the light these factors may shed on what healthcare institutions should be paying attention to if they want telehealth adoption to continue to expand.

Relative advantage

The relative advantage of virtual visits over in-person visits greatly increased with the onset of the pandemic. In a pre-COVID world, telehealth’s most obvious advantage to a patient was convenience. However, this relative advantage was often offset by the perceived disadvantage of impersonal care, with patients and even practitioners concerned with the quality of care received virtually.

In the midst of a pandemic, though, with social distancing regulations, shelter-in-place orders, and a general heightened concern over health, the advantage of telehealth became clear. In addition to convenience, virtual visits were a safer solution, especially for those with chronic illnesses that need continual care.

Once concerns over the virus subside, will the perceived relative advantage of safety completely go away? And if it does, will the remaining advantage of convenience be enough to sustain the growth of telehealth?

In the calculus of relative advantage, it is important to look equally closely at the relative disadvantage factors as well. What are telehealth providers doing now to mitigate the concern with the quality of care in a telehealth visit? While telehealth is in use, what additional innovation is happening to make telehealth a better delivery method for medical care?

Is the perceived disadvantage of impersonal care being mitigated by the actual experience of a friendly and personalized experience delivered through telehealth?

Is the perceived disadvantage of impersonal care being mitigated by the actual experience of a friendly and personalized experience delivered through telehealth? While it may be a struggle, these soft factors are critically important and must not be ignored if this extraordinary moment is to be leveraged for further adoption of telehealth.

Telehealth providers who wish for its expansion to continue will not only need to keep improving the quality of the medical services delivered through telehealth, but they will also have to do a better job of communicating the relative advantage. To try anything new, people usually need a compelling reason, an obvious advantage that the new way has over the current ones that are supported by habit. The pandemic provided that reason and in the process broke the habits of many, but if providers of telehealth wish for this new normal to persist, they’ll need to make a good case for its advantages going forward and make a concerted effort on quality improvement. Without these two things, the old habits will quickly reassert themselves and we could be right back where we left off before the pandemic.

Compatibility

Telehealth’s compatibility, or the ease with which an innovation can be integrated into daily life, was dramatically improved with the onset of the pandemic. While a virtual health appointment could have been seen as out of place before, in a world of Zoom meetings, classes, and hangouts, telehealth fits seamlessly into this new state of affairs. The pandemic effectively removed most barriers to telehealth adoption.

But how much of this new normal will persist as the pandemic subsides? After growing used to virtual communications, patients may continue to be receptive to telehealth, but there could also be a rejection of it as patients actively seek to restore some of their pre-pandemic behaviors in assertion of “normalcy.”

Providers of telehealth who wish to extend its adoption after the pandemic will have to proactively reinforce the new behaviors.

Providers of telehealth who wish to extend its adoption after the pandemic will have to proactively reinforce the new behaviors, taking maximum advantage of the compatibility that exists now. Those who wait too long or who secretly wish for the return themselves will in many cases lose this once-in-a-generation opportunity of extraordinary compatibility with a new behavior. The focus should be on creating as seamless and positive an experience as possible. A psychological sense of normalcy in this new behavior should be cultivated among caregivers and patients. This likely means training and planning with internal stakeholders, making it clear that the aim is to preserve this new behavior and not to project any longing or nostalgia for the way things were. This may be hard in the face of a feeling of loss among medical practitioners.

Complexity

A classic struggle for an innovation and complexity—both real and perceived—of any new practice has a discouraging effect on its adoption. This was a key obstacle to telehealth adoption prior to the pandemic. Why would a patient bother to figure out how to work the technology for a virtual health visit when it was so easy to show up for an in-person appointment? The onset of remote working for most thought workers during the pandemic has significantly flattened the perceived complexity barrier for all forms of remote interactions. This dovetailed with a set of highly user-friendly technologies such as Zoom that have allowed a large swath of the population to pass through the complexity barrier, learning how to operate virtual communication tech. In this context, telehealth now seems no more complex than the online video calls most have been practicing daily, if not hourly, for months.

The universality and persistence of the pandemic in the US in particular means that these newly acquired technology skills will be well practiced by the time the pandemic finally ends. So a large swath of the US population will emerge with improved capability using virtual communication technology, and so the average patient will be much less likely to be deterred by telehealth’s perceived complexity.

The universality and persistence of the pandemic in the US in particular means that these newly acquired technology skills will be well practiced by the time the pandemic finally ends.

This does not mean that providers can remain complacent, however. While the pandemic has reduced the complexity of telehealth by ushering in the mass adoption of virtual tech, providers must still work to resolve any other complexities in their particular telehealth platforms.

Along with this widespread adoption, there has also been a widespread raising of expectations surrounding how virtual communications should work. Any telehealth platform will automatically be compared from a user experience and ease of use perspective to the easiest and most widely used technologies. This lowers people’s tolerance to cumbersome or poorly performing services. Any point of friction, or the unnecessary expenditure of time, effort, or money, should be identified and, to the extent possible, systematically removed to make complexity a non-issue.

Trialability

How easily an innovation can be sampled and experimented with is another influential factor. In the case of telehealth adoption, it became markedly easier to participate in virtual health visits because of the pandemic. Prompted by the virus and the easing of federal barriers to telehealth, there was nearly a 40% jump in physicians offering telehealth between 2019 and 2020—almost double the typical year-on-year increase.

The expansion of the offer made it far easier for patients to try out virtual healthcare services. More effort than ever has been invested in promoting telehealth as an option, so we are in a kind of perfect storm for trialability now, but these conditions will soon change.

Whether or not telehealth will be just as easily available and well-promoted post-pandemic is dependent on providers. What is in it for them to preserve this state of affairs that puts greater emphasis on telehealth and a tool in their arsenal of care? How frustrating has it been for professional caregivers? How well were they trained on using the new technology? What aspects of in-person care are they missing? There are factors of internal inertia that may encourage a slide back to the old status quo once the opportunity arises. Any institution that desires to keep this process moving forward should be mindful of this and actively seek to pave the way for fuller adoption and actively support or incentivize the behaviors it seeks to foster.

Establishing a new habit takes time and in the case of the pandemic, the adoption of telehealth is affording practitioners and patients the opportunity to experiment with this way of doing things.

All of this work behind the scenes results in a good or bad customer experience. The better that experience is during this trial phase, the more likely that the resistance to continued adoption will be reduced. Old habits do not die easily. Establishing a new habit takes time and in the case of the pandemic, the adoption of telehealth is affording practitioners and patients the opportunity to experiment with this way of doing things. However, it should not be considered a given that this will all continue after the special conditions created by the pandemic subside. If the expected benefits of telehealth outweigh the concerns, health systems need to be proactive both internally and in terms of patient experience, if they truly want it to stay.

Observability

If an innovation’s benefit is easily observed, then the adoption rate of that innovation greatly increases as more and more people are exposed to it. This is the herd mentality at work. If the adoption of the new behaviors can be easily observed, this will normalize the adoption of the associated behaviors. Unfortunately, the private nature of telehealth makes it difficult for its benefits to be observed. Telehealth has some observability within the context of those with whom a person shares their private lives, but more broadly, it is not an activity that lends itself easily to public display. This element, therefore, is largely absent.

Organizations wishing to promote telehealth should make an effort to normalize it in advertising.

The onus of addressing this then falls on the organizations that wish to promote telehealth. They should make an effort to show it in advertising and encourage it to be written into television and film scripts. Telehealth needs to be seen as normal and good.

Telehealth adoption in a post-pandemic world

COVID-19 altered the condition of the world in a way that allowed telehealth adoption to skyrocket. Suddenly, virtual healthcare visits are perfectly compatible with patients’ lifestyles and no more complex than the technology that was being widely used in the workplace.

But as things transition to a post-pandemic future, some of the factors that had positively influenced the rapid adoption of telehealth will not hold. The window of opportunity that this terrible moment presents will soon close. Old habits are surprisingly tenacious and tend to reassert themselves when the opportunity arises. Telehealth providers who want to push for its continued expansion should look to leverage any and all of the five factors of the Diffusion of Innovation Theory to determine where to focus their efforts now and as we move ahead.

Providers who want to push for continued expansion of telehealth should look to leverage any and all of the five factors of the Diffusion of Innovation Theory.

With low observability, more resources could be put into advertising campaigns that promote telehealth’s benefits in a tangible and observable way. At the risk of having a weaker relative advantage to in-person visits once the pandemic subsides, providers should also be proactive in developing and growing its advantages. Telehealth has the potential to do a lot of good. Understanding and improving the factors that can lead to greater adoption is key to the long-term diffusion of this innovation.

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Composite image sourced from Günter Valda and Dorrell Tibbs on Unsplash