Understanding How Patient Engagement is Enacted through Telehealth: A Grounded Theory Study

Background: The COVID-19 pandemic forced a sudden shift in how healthcare was provided leading to a rapid implementation of telehealth in March 2020. While telehealth had been used in some populations and areas, it was not widely implemented throughout the U.S. Healthcare organizations were challenged to implement telehealth overnight for people to continue to seek medical care. Regulations related to reimbursement and medical licensing were loosened during the COVID-19 pandemic which removed some of the long-standing barriers to telehealth. As telehealth continued in practice, providers and practices were challenged to find new and creative ways to engage patients through telehealth. Patient engagement has long been studied in healthcare and found to be an effective strategy to meet the quintuple aim of healthcare. Despite the effectiveness of patient engagement in many healthcare settings, it had not been widely studied in telehealth before the COVID-19 pandemic. Despite the vast amount of literature related to telehealth and patient engagement separately, including several models and frameworks, a gap remained in the literature about how patient engagement occurs in telehealth. Objective: The purpose of this study was to construct a theory of how patient engagement was enacted in the ambulatory setting through telehealth. To develop a theory about how patient engagement occurs in telehealth, the researcher sought to understand how patients and providers described patient engagement. This study focused on the experiences of patient and providers using telehealth in various ambulatory settings to understand factors that promote or hinder patient engagement, strategies used for patient engagement, and the impact on health outcomes. Methods: A qualitative, grounded theory method was used to create a theory that explains the process of how patient engagement occurs in telehealth. Corbin and Strauss’s (2015) systematic approach to grounded theory was used. Data was collected through focus group interviews, document review, and semi-structured interviews. The focus group included three providers who shared their experiences with the implementation of telehealth at the academic medical practice as well as identification of telehealth documents for review, and recommendations for clinics to participate in the study. Over 30 documents were shared for review. Interview participants included 10 providers and nine patients from three different clinics that were part of a large academic medical practice in Washington, D.C. The data was analyzed using a process that consisted of open, axial, and selective coding that followed a constant comparative approach. Study participants were invited to participate in a focus group or provide electronic feedback on the axial coding diagram as a form of member checking. Results: This study resulted in the development of a theory on how patient engagement occurs through telehealth. Participants in this study described patient engagement in terms of an exchange of information, active involvement, and mutual understanding. Based on the description of patient engagement and analysis of the study data, the theory developed was based on the central category that was identified as building trust between patients and providers. Four key components were identified to support this core category which include ensuring appropriate use of telehealth, enhancing mindful communication, building reciprocal relationships, and interacting more frequently. When all of these components were present and patients and providers were able to build trust when using telehealth, health outcomes either remained the same as in-person or were improved. Conclusions: This study gained knowledge from patient and providers that experienced telehealth since the start of the COVID-19 pandemic. Developing a theory about the process of how patient engagement happens in telehealth is a significant step toward better understanding what is needed to support effective telehealth practices moving forward. This study expands the base of literature about patient engagement and begins to bridge a gap in the literature around patient engagement and telehealth together. This theory found that the key to patient engagement in telehealth is the need for patients and providers to build trust between each other. This trust is garnered from having the appropriate structures and processes in place for telehealth that allow patients and providers the ability to have mindful communication where both voices are heard. This will lead to developing a reciprocal relationship that is enhanced by the reality that telehealth has allowed patients and providers to interact more frequently. This is the first study to explore how patient engagement happens in telehealth. This study generates new knowledge that can now be translated into different areas using tools such as the Knowledge-to-Action Framework where it can be applied to different settings or populations. Organizations can use the Deyo’s Engaging Patient’s in Telehealth Checklist that was developed by the researcher by translating the findings of this study into a practical tool. There are many implications for theory, practice, policy, and research need to continue being explored