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. Author manuscript; available in PMC: 2023 Oct 6.
Published in final edited form as: JU Open Plus. 2023 Sep;1(9):e00044. doi: 10.1097/ju9.0000000000000049

Practical Strategies for Addressing Video Visit Access Barriers in Urology

Husain Abizer Rasheed 1, Olivia Hazelrigg 2, Patrick Magnus Rasmussen 3, Hamza Mustafa Raja 4, Mary C Blazek 5, Julia Chen 6, Chad Ellimoottil 7
PMCID: PMC10558116  NIHMSID: NIHMS1930078  PMID: 37810579

INTRODUCTION

Over the last three years, telehealth usage surged as providers strived to deliver healthcare while optimizing safety in the midst of the COVID-19 pandemic. Telehealth has provided an avenue for clinicians to continue caring for their patients while reducing risk of COVID-19 transmission, and this is in part made possible by the ubiquity of smartphones and other video- and audio-enabled devices (85% of all Americans own a smartphone.)1 However, data shows that certain populations, such as senior citizens, minorities, and rural Americans, have proportionally less access to telehealth compared to the average American.1,2

This digital divide stratifies current social disparities in access to healthcare; therefore, identifying and addressing obstacles to digital healthcare remains critical. Previous work has defined the various factors that can impact access to telehealth-compatible devices and telehealth overall, including income, race and ethnicity, lack of familiarity with video conferencing software, and availability of stable Wi-Fi, to name a few.3,4 At this time, there is a paucity of research exploring how to overcome these gaps in access to virtual healthcare. The existing literature suggests that interventions such as distribution of instructional paper handouts to patients to prior to their telehealth visit were helpful in overcoming telehealth and computer literacy issues.5 Additionally, patients have derived benefit from receiving a call from support personnel prior to their video visit to ensure the presence of telehealth compatible technology, appropriate software download, and ability to navigate these technologies and connect to the visit; these support personnel would then help troubleshoot any barriers that emerge in this pre-telehealth visit phone call.5,6

We aim to analyze specific strategies for overcoming barriers to telehealth access through an evaluation of data collected by a medical student-run telehealth education program. Our hope is that these findings will support other urology practices trying to expand video visits to all of their patients in an equitable manner.

GET Access Program and Study Population

Data was collected from the University of Michigan’s Department of Urology between April 7, 2022 and July 6, 2022 through the GET (Geriatric Education On Telehealth) Access Program. GET Access is a medical student-run volunteer program that was originally created to assist geriatric patients—a population with decreased technological access and literacy—with understanding and gaining access to telehealth services during the COVID-19 pandemic.7 This volunteer program has now expanded to assist other patient populations in multiple other specialties including Urology.

The GET Access program works in several steps. First, patients are selected by call center agents and queried about their interest in video visits. The call center utilizes a decision tree created by clinicians in the department to identify who to offer virtual visits to based on presenting symptoms and diagnosis. Every patient who was offered a telehealth visit was asked if they needed assistance. If patients were indicated as needing assistance, they were forwarded to our medical student volunteers through an electronic inbox pool system in the electronic medical record. Volunteers then called patients to identify how they needed assistance with their telehealth visits, and found creative ways to solve any potential problems. Medical student volunteers were given specific weekday shifts when they would call patients. If the volunteer was unable to reach the patient, a voicemail and/or email was sent with further instructions to assist the patient with their virtual visit. The patient would remain in the inbox pool if a volunteer could not directly reach them by phone. If three subsequent volunteers were unable to reach a patient, then that patient was removed from our inbox pool. There were three medical students volunteering on the urology service; together, they called about 10 patients per week. The volunteers also had an internal group forum to communicate pertinent updates and to support each other.

Data Collection and Analysis

The information gathered from these calls was securely documented ensuring seamless communication between volunteers and accuracy of data for analysis. We reviewed all Get Access Volunteer encounters in the Department of Urology with no inclusion or exclusion criteria. A spreadsheet was created to track the following parameters for each patient that was contacted: which and how many volunteers attempted to contact the patient, age, sex, race, insurance status, provider name, date and length of troubleshooting call, date of appointment, and outcome of volunteer assistance. We created a free text column indicating the challenges the patient experienced and how they were resolved. We analyzed this data as a team using an inductive approach. Through reflexive thematic analysis, we generated themes on the issues faced by patients and concluded adequate data saturation.

This study was deemed exempt from review by the University of Michigan’s institutional review board because it was a quality improvement study.

RESULTS

We contacted 47 patients during the study period. The estimated time spent with each patient on the phone was seven minutes, but varied widely based on patient needs. Patient demographics are described in table 1, indicating a wide range of ages; 23 (48.9%) were older than 40. 28 (59.6%) of patients in the study have private insurance. We were not able to reach 10 (21.28%) of patients after calling on three different days. These patients received a voicemail and email with instructions on access to further support and next steps to ensure successful virtual visits. Of these 10 patients, 8 (80%) went on to have a successful video visit. 7 (14.9%) of patients that picked up the phone declined assistance or had already received adequate support.

Table 1:

Characteristics of Patients Assisted in Get Access Urology Program

Characteristics Patients (n=47)
Age (%) <1 year old 4 (8.51%)
1–18 10 (21.28%)
19–40 10 (21.28%)
41–64 9 (19.15%)
65+ 14 (29.79%)
Sex (%) Male 28 (60%)
Female 19 (40%)
Race (%) Non-hispanic white 28 (59.58%)
Black (or African-American) 10 (21.28%)
Asian/Pacific islander 2 (4.26%)
Hispanic 4 (8.51%)
American Indian/Alaska Native 1 (2.13%)
Other/Unknown 2 (4.26%)
Insurance Status (%) Medicare/Medicaid 15 (31.91%)
Private 28 (59.58%)
None 4 (8.51%)
Length of Call (%) 1–2 minutes 8 (17.02%)
3–5 minutes 16 (34.04%)
6+ minutes 13 (27.66%)
Sent Voicemail and/or email 10 (21.28%)
Outcome of Call (%) Kept scheduled video visit 40 (85.1%)
Converted video visit to phone visit or in-person visit 2 (4.26%)
Other 5 (10.63%)
a

Percentages may not equal 100 due to rounding.

b

Race was defined using Research Triangle Institute race code in the Master Beneficiary Summary File (MBSF).

We encountered 4 main themes during our discussions with patients. These include: completion of registration steps, familiarity with accessing and using video conferencing software, attainment of proxy access for parents of a pediatric patient, and resolution of miscellaneous technical queries.

Theme #1: Completion of Registration Steps

The registration process is not intuitive for all patients, thus carefully explaining the process over the phone is often necessary. The most frequent barrier faced by patients was with the registration process and specifically joining the patient portal. Learning to use new technologies and modules can be difficult and scary for some. Thus, volunteers were taught beforehand various communication skills and scenario based training for dealing with push backs to utilizing video visits. Volunteers motivated patients to step out of their comfort zone and spoke with empathy to guide patients through new processes. First, volunteers assessed the patient’s technological comfort and social situation by asking a series of questions to gauge the best way to assist the patient. Most pertinently, patients were screened on access to video enabled devices, wifi access, comfort with technology, and availability of assistance in the household with registration for technologically challenged patients. Volunteers then initiated the registration process by emailing patients an invite link to join the patient portal. At our institution, one of the first steps for video visit registration is accessing the patient portal. Along with enabling video visits, it is also crucial in the long term for patient communication and access to important personal medical data. Then, volunteers explained step by step how to join the portal, enter the correct information, and download the mobile or tablet application, if relevant. Volunteers also showed patients where to find their video visit information and where to complete the pre-check-in process through their portal. 30 (81%) of patients benefited from this service. On multiple occasions, patients were surprised by the seamlessness of the process, and expressed their gratitude to volunteers for easing them into this new space.

Theme #2: Familiarity with Accessing and Using Video Conferencing Software

Having access to video conferencing software on a video-capable device, along with experience using the application, is highly beneficial in ensuring seamless telehealth visits for patients. After completing the registration process described above, volunteers then assessed patients’ access to the correct video conferencing software on their device. Our institution uses the Zoom application for video visits, thus volunteers provided patients with a walkthrough of downloading the Zoom application on their specific device. If a patient was unable to complete these steps on their own, attempts were made to have a household member or caregiver assist the patient with this process. After ensuring the previous steps are completed, all patients were offered to practice a conference call with a volunteer prior to their virtual visit. Patients were sent a link to their email with a practice video visit call, allowing individuals to test out their video and audio with a volunteer, and overall get comfortable with the virtual environment. This service was utilized by 12 (32.5%) of patients. One patient noted how useful this was and how it also allowed them to use video conferencing applications effectively for other personal needs, like connecting with family members.

Theme #3: Attainment of Proxy Access for Parents of a Pediatric Patient

Obtaining patient portal access can be critical in pediatric healthcare for fostering family engagement, facilitating care coordination, and ensuring successful telehealth visits. 10 (71.4%) of 14 pediatric patients required assistance obtaining portal proxy access. Addressing the challenges associated with acquiring portal proxy access has the added benefit of enhancing the involvement of families in their child’s healthcare journey, optimizing coordination among healthcare providers, and maximizing the effectiveness of telehealth visits in pediatric settings. However, directly granting parents or guardians proxy access can be challenging because of the strict privacy and security policies. Thus, volunteers first guided parents through the proxy access request wizard on the portal website. If unsuccessful or if parents did not have the necessary information, volunteers referred them to the portal access hotline. During the process of acquiring proxy access, parents often expressed frustration due to the tedious nature and the time it took to complete the procedure. Therefore, it was crucial for volunteers to exhibit patience and understanding while assisting them, and emphasize the significance and benefits of obtaining portal access. By emphasizing the value of portal access, volunteers played a vital role in alleviating frustration and motivating individuals to obtain access into their loved one’s healthcare.

Theme 4: Resolution of Miscellaneous Technical Questions

During the course of volunteer interactions with patients, a myriad of additional issues emerged. These included matters such as resolving password issues, navigating different parts of the portal website, rescheduling appointments, challenges related to wireless connectivity, specific inquiries concerning their video-capable devices, and issues related to pairing hearing aids or earpieces, among various other patient-specific factors. Password problems were the most commonly faced technical issue. These can be logistically difficult to resolve and are a hindrance to accessing the portal and having a successful virtual visit. The simplest form of support was connecting patients to the password reset portal. However, patients in this situation often did not know their username and/or email address on file, which made the process more difficult. We then referred them to the IT team that could address this issue directly. Having to reset their password can be frustrating for patients; however, due to security and privacy policies, this is the only viable way of restoring access to the portal. To ensure that a patient’s password problem was resolved and that he/she was fully prepared for the virtual visit, another volunteer then followed up with this patient on the next shift. Volunteers noticed a common trend: namely, that these patients had signed up for the portal long ago and often confused their portal password with email and other platform passwords. Furthermore, for patients who have caregivers or family members involved in their healthcare management, there were queries about how to include them in virtual visits from separate locations or effectively communicate the information discussed during our conversation to the caregiver. We generally found that implementing two strategies greatly enhanced patient engagement and understanding. The first approach involved encouraging patients to write down the key points discussed during the call. This helped reinforce important information, promote better retention, and allow for caregiver reference. Alternatively, we employed the teach-back method, which involves patients summarizing the key concepts discussed to ensure their comprehension and competency. With some queries requiring support beyond the scope of the program, volunteers referred patients back to the clinic call center to address these issues. Although volunteers weren’t always able to provide direct assistance to patients, they had the resources and contacts needed to guide patients in solving their technical issues.

DISCUSSION

By operationalizing the Get Access program for urology, we found that the main obstacles impeding video visits were (1), completion of registration steps; (2), familiarity with accessing and using video conferencing software; (3), attainment of proxy access for parents of a pediatric patient; and (4), resolution of miscellaneous technical queries. We addressed these issues through a structured workflow algorithm (Figure 1), that provided patients with an opportunity to receive a live walkthrough of the steps for registering for a video visit, practice with the video conferencing software, and guidance to resources and answers to any issues in the process.

Figure 1:

Figure 1:

Volunteer Workflow Algorithm

Our findings are consistent with prior research that suggests that significant patient barriers to telehealth include comfort with technology, and low use of the patient portal.8 In a comprehensive review, Raheem et al identified common barriers to telemedicine integration. Their literature review echoed our findings such as technological barriers including comfort and familiarity with technology, as well as consistent use of the patient portal.9 In a review conducted by Naik et al., several challenges were identified with telemedicine in urology including technical difficulties like software issues, lack of video-compatible devices, and insufficient high-speed internet, along with a variance in patients’ technological fluency and health literacy. Complications arising from newly implemented procedures like obligatory enrollment in patient portals, coupled with a lack of comprehensive training by healthcare systems, also formed barriers, particularly for vulnerable populations.10 In addition to identifying video visit failure risk factors based on ethnicity, insurance, and diagnoses, Shee et al. also identified technology factors such as access to the patient portal and patient reminders as factors in the success rate of video visits.11 According to Dubin et al, the greatest concerns shared by urologists with regard to telehealth include patients’ technological competence, lack of access to technology, and reimbursement.12 Although our study did not specifically focus on technology infrastructure or reimbursement, our qualitative analysis identified technological competence and patient portal access as notable barriers to telehealth access.

Our study had a few limitations. Firstly, it was conducted in a single institution, which may limit the generalizability of our results to those who use a similar platform. However, our institution serves a broad range of patients, and the makeup of this population is generalizable to other urology practices. Furthermore, we believe our four themes are generalizable. Additionally, language barriers and socio-economic status are potential confounding variables that are not addressed by the results of our study. Finally, only patients who were scheduled for a video visit and asked for assistance were included in the study. Therefore, our approach may miss the barriers faced by patients who completely declined a video visit.

These limitations notwithstanding, we believe our findings and practical strategies are helpful for urology practices that are interested in starting or expanding the use of video visits. It is inevitable that a population of patients will have difficulty using the technology. Our practical strategies may help focus efforts on training staff or volunteers who may interact and help patients overcome technical barriers to video visit use. Of note, the medical students who volunteered for the GET Access program found it a formative experience, training them in medical chart navigation and patient interaction.

While some urology practices may lack the resources and capability to implement a similar program, there are numerous cost-friendly solutions available. Implementing a structured stream of communication tailored to the clinic’s workflow is crucial. By customizing the communication process, clinics can effectively and securely coordinate patient interactions, share information, and address inquiries, optimizing the telehealth experience for both patients and healthcare providers. It is essential to ensure that any chosen communication method is HIPAA compliant to maintain patient privacy and confidentiality. A summary of telehealth recommendations for urology practices is described in Table 2.

Table 2:

Telehealth Recommendations for Urology Practices

Offer comprehensive and user-friendly instructional materials, including handouts and digital guides. These resources should provide clear step-by-step instructions that are easy to follow, ensuring patients feel informed and ready for their virtual appointments.
Develop informative walkthrough videos tailored for different commonly used video-enabling devices, such as laptops, tablets, and smartphones (including both Android and Apple devices). By providing device-specific instructions, patients can easily follow along and gain confidence in navigating their specific device for telehealth appointments.
Provide telehealth support via phone before a video visit by leveraging the assistance of various individuals, such as medical students, clerks, IT staff, undergraduate students, work study members, volunteers, and others. Importantly, only a minimal medical knowledge base is required for these individuals to effectively offer support.
Offer patients the opportunity to participate in practice video visits with a volunteer or staff member.
Establish a well-structured communication system customized to the clinic’s workflow. Fortunately, there are various cost-effective modalities available that can be acquired. For instance, clerks can utilize a secure dropbox designed for handling protected health information, or utilize tools like Excel or paper forms, depending on the scale of the practice. Regardless of the chosen method of communication and documentation, it is of utmost importance to prioritize and maintain patient confidentiality.
Develop a clear and concise decision tree or flowchart that clinic staff or volunteers can utilize to efficiently and effectively address patient telehealth issues.
Utilize effective strategies during patient interactions, such as employing the teach-back method, encouraging patients to take notes, and involving caregivers when applicable.
Offer special training for parents or guardians to enable proxy access, and address any specific concerns related to the use of telehealth for pediatric care.

CONCLUSIONS

In summary, this program was a feasible and low resource way to improve video visit adoption. The practical strategies outlined in this paper can be valuable for urology practices seeking to expand their use of video visits in an equitable manner, while ensuring patient privacy and confidentiality. When a telehealth program is being designed, it is important to address the concerns of completing registration steps, utilizing video conferencing software, proxy access, and answering miscellaneous technical questions.

ACKNOWLEDGMENTS

Funding sources

  • 5K08HS027632-03 from the Agency for Healthcare Research and Quality (Ellimoottil)

  • 9L30DK133968-03A1 (Ellimoottil) National Institute of Diabetes and Digestive and Kidney Diseases

No funding organization was involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Contributor Information

Husain Abizer Rasheed, University of Michigan Medical School, Ann Arbor

Olivia Hazelrigg, University of Michigan Medical School, Ann Arbor

Patrick Magnus Rasmussen, University of Michigan Medical School, Ann Arbor

Hamza Mustafa Raja, University of Texas Medical Branch, Galveston

Dr. Mary C Blazek, University of Michigan, Ann Arbor, Department of Geriatric Psychiatry

Julia Chen, University of Michigan, Ann Arbor, Department of Internal Medicine

Chad Ellimoottil, University of Michigan, Ann Arbor, Department of Urology

REFERENCES

  • 1.Mobile Fact Sheet. Pew Research Center: Internet, Science & Tech. Published April 7, 2021. Accessed September 20, 2022. https://www.pewresearch.org/internet/fact-sheet/mobile/
  • 2.Vogels EA. Some digital divides persist between rural, urban and suburban America. Pew Research Center. Published August 19, 2021. Accessed September 20, 2022. https://www.pewresearch.org/fact-tank/2021/08/19/some-digital-divides-persist-between-rural-urban-and-suburban-america/ [Google Scholar]
  • 3.Kan K, Heard-Garris N, Bendelow A, Morales L, Lewis-Thames MW, Davis MM, Heffernan M. Examining Access to Digital Technology by Race and Ethnicity and Child Health Status Among Chicago Families. JAMA Netw Open. 2022;5(8):e2228992. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Triana AJ, Gusdorf RE, Shah KP, Horst SN. Technology Literacy as a Barrier to Telehealth During COVID-19. Telemed J E Health. 2020;26(9):1118–1119. [DOI] [PubMed] [Google Scholar]
  • 5.Thelen-Perry S, Ved R, Ellimoottil C. Evaluating the patient experience with urological video visits at an academic medical center. Mhealth. 2018;4:54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Rimmer RA, Christopher V, Falck A, de Azevedo Pribitkin E, Curry JM, Luginbuhl AJ, Cognetti DM. Telemedicine in otolaryngology outpatient setting-single Center Head and Neck Surgery experience. Laryngoscope. 2018;128(9):2072–2075. [DOI] [PubMed] [Google Scholar]
  • 7.Pichan CM, Anderson CE, Min LC, Blazek MC. Geriatric Education on Telehealth (GET) Access: A medical student volunteer program to increase access to geriatric telehealth services at the onset of COVID-19. J Telemed Telecare. Published online June 21, 2021:1357633X211023924. [DOI] [PubMed] [Google Scholar]
  • 8.Chang JE, Lai AY, Gupta A, Nguyen AM, Berry CA, Shelley DR. Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID Era. Milbank Q. 2021;99(2):340–368. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Brimley S, Natale C, Dick B, Pastuszak A, Khera M, Baum N, Raheem OA. The Emerging Critical Role of Telemedicine in the Urology Clinic: A Practical Guide. Sex Med Rev. 2021;9(2):289–295. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Naik N, Hameed BMZ, Nayak SG, Gera A, Nandyal SR, Shetty DK, Shah M, Ibrahim S, Naik A, Kamath N, Mahdaviamiri D, D’costa KK, Rai BP, Chlosta P, Somani BK. Telemedicine and Telehealth in Urology-What Do the “Patients” Think About It? Front Surg. 2022;9:863576. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Shee K, Liu AW, Yarbrough C, Branagan L, Pierce L, Odisho AY. Identifying Barriers to Successful Completion of Video Telemedicine Visits in Urology. Urology. Published online August 15, 2022. doi: 10.1016/j.urology.2022.07.054 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Dubin JM, Wyant WA, Balaji NC, Ong WL, Kettache RH, Haffaf M, Zouari S, Santillan D, Autrán Gómez AM, Sadeghi-Nejad H, Loeb S, Borin JF, Gomez Rivas J, Grummet J, Ramasamy R, Teoh JYC. Telemedicine Usage Among Urologists During the COVID-19 Pandemic: Cross-Sectional Study. J Med Internet Res. 2020;22(11):e21875. [DOI] [PMC free article] [PubMed] [Google Scholar]

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