Contraceptive care providers and staff wish to sustain telehealth long past the COVID-19 pandemic era in which telehealth was more widely used, according to a recent study of telehealth in Illinois.1
“We were trying to understand what the rapid response to the early days of the COVID-19 pandemic meant for contraceptive care and what the lessons were for the future,” says Debra Stulberg, MD, study co-author and a professor and chair in the department of family medicine at the University of Chicago.
Researchers studied perceptions of real-time, synchronous interaction — not other types of remote interactions, such as chart messages, patient portals, or anything handled through apps or texting. They interviewed clinicians, clinical staff, and some scheduling and administrative staff, but did not speak to patients.
“We were focused on people who, prior to the pandemic, were providing contraceptive care in person,” Stulberg explains.
During the pandemic, they pivoted to telehealth-only or a hybrid of telehealth and in-person visits. “Even after a few months, we all knew that telemedicine was not going away,” she adds. “It was something we were thinking about and trying to implement at different points of the healthcare system. The pandemic forced us to do it, and it’s likely to stay.”
Stulberg and colleagues wanted to know more about the immediate ramp-up in telemedicine and lessons for innovative care delivery. They wanted to see how telehealth could work for contraceptive care specifically. “The providers we spoke to were overall very positive about telemedicine for contraceptive care,” Stulberg says. “They felt it improved access, and they felt in many patient encounters it was a very patient-centric, user-friendly way of providing contraception.”
These encounters included contraception counseling and conversations about starting a new method or renewing a prescription that worked well for patients. It was all well received, although some situations presented both positives and challenges.
“Certainly, people interested in a LARC method [would] have to be seen in-person to get LARC inserted,” Stulberg says. “Some people said any counseling needed for LARC could be done by a phone or video visit, and this would save the patient from having to come in twice: once for counseling, and the other for insertion.”
In other locations, patients could obtain LARC with just one in-person visit, so a telehealth visit would delay achieving their contraception of choice.
“For patients who are already confident they want a LARC device, there’s not a clear role for telehealth. It’s great when it can be done in one day,” Stulberg says.
Even before the pandemic, there was a movement toward same-day LARC access and eliminating the need for two visits. “The findings from these interviews emphasized that for some patients, there’s not a need for a whole separate counseling visit,” she adds.
Another area of concern with telehealth visits was privacy for adolescents and anyone else for whom in-home privacy was difficult to achieve.
“A home visit or any setting where the patient might be during a telehealth visit that wasn’t clearly private posed a challenge in some situations,” Stulberg says. “They would try to see at the start of the visit if the patient could talk about sensitive topics, and if the patient could not, that would make the telehealth visit difficult.”
The opposite experience also was true for some patients. Some providers said their patients were not always comfortable visiting a family planning clinic, and they would find that telehealth enhanced privacy.
“Another area where we found mixed [findings] had to do with visual cues and rapport formation,” Stulberg says. “Some providers articulated that having a patient in person is better for building rapport. When patients are on the phone or video, they may be distracted, or they can’t observe their body language well.” Also, eye contact is more difficult through video calls. That is important for the patient-provider relationship, she adds.
When asked about bias, some providers expressed the opposite thought. “Some reflected that when they were on an audio-only visit, rather than video or in-person, it could actually be helpful because they weren’t taking in visual cues that would bias them,” Stulberg noted. “They’d say, ‘With a phone call, I hear from the patient what they want,’” Stulberg says. “That’s an interesting reflection.”
There were potential upsides to video calls, but also potential upsides to phone conversations when it comes to preventing potential bias.
“Interviews were done over Zoom or phone, and we asked a question of whether they perceived it affected bias in care,” Stulberg says. “Our whole study team was aware that implicit bias exists everywhere, and there is a lot of research that it exists in medicine.”
The reproductive justice movement has shed light on bias and coercive practices, such as encouraging teenagers to use LARC because they cannot be trusted to take a pill every day. “Or a low-income-level person who has a lot of kids should have a long-acting method,” Stulberg adds. “Patients have described experiencing that out in the world, and we wanted providers to reflect on that.”
Once providers reflect on their potential bias and how this affects contraceptive counseling and care, they can change some of their patient interactions. Instead of assuming a patient may prefer LARC because it is safe and most effective, they can ask patients questions about their own preferences and goals.
“Our job is to verify: ‘Would you like to have more children? Are you interested in the most effective method?’” Stulberg explains.
Another takeaway is that telehealth should be funded in a way that allows flexibility. Providers need to find out what type of visit works well for an individual patient.
“Not all payers are reimbursing equally for video visits or phone visits,” Stulberg explains. “The broader lesson for policymakers and clinicians is flexibility for patients can go a long way when it comes to health.”
Flexibility is about using a phone if the electronic platform does not work for a provider or patient. “I would encourage clinicians to get creative with ongoing barriers,” Stulberg says. “For example, if you’re talking to someone, and they aren’t able to be in a private space because there are too many people around them, then they could move to chat function or texting.” Providers can offer patients other ways of communicating for follow-up visits and information.
Family planning providers also can be flexible in how patients receive their birth control injections by offering patients the option of self-injection.
“Patients could pick up their Depo shot from the clinic or pharmacy and self-inject at home,” Stulberg says. “Self-injection at home came up as appealing [in the study]. It’s an innovation that didn’t have to depend on the pandemic but seemed to work in the pandemic.”
A third area of flexibility can involve blood pressure checks for estrogen contraceptives. “Where else can they get their blood pressure checked if they don’t want to go to the clinic?” Stulberg asks. “Some providers talked about sending a blood pressure cuff to patients or having them go to a blood pressure kiosk and call with results.”
The COVID-19 pandemic forced the healthcare workforce to become flexible. This attitude would work going forward.
“As we ask clinicians to be more flexible and creative, the organizations need to build in support for that, including training and having technical staff ready,” Stulberg says. “Clinicians said they were going to keep telehealth and were quite excited moving forward.”
REFERENCE
- Huang I, Delay R, Boulware A, et al. Telehealth for contraceptive care: Lessons from staff and clinicians for improving implementation and sustainability in Illinois. Contracept X 2022;4:100083.
Contraceptive care providers and staff wish to sustain telehealth long past the COVID-19 pandemic era in which telehealth was more widely used, according to a recent study of telehealth in Illinois.
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