Discovering untapped relationshippotential with patients in telehealth:a qualitative interview study

Birgit Heckemann,1 Axel Wolf,2 Lilas Ali,2 Steffen Mark Sonntag,3 Inger Ekman2

To cite: Heckemann B,Wolf A, Ali L, et al.Discovering untappedrelationship potential withpatients in telehealth:a qualitative interview study.BMJ Open 2016;6:e009750.doi:10.1136/bmjopen-2015-009750

▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2015-009750).

Received 18 August 2015Revised 23 December 2015Accepted 31 December 2015

For numbered affiliations seeend of article.

Correspondence toBirgit Heckemann;b.heckemann@maastrichtuniversity.nl

ABSTRACTObjectives: To explore factors that influencerelationship building between telehealth professionalsand patients with chronic illness over a distance, froma telehealth professional’s perspective.Design: 4 focus group interviews were conducted inJune 2014. Digital recordings were transcribedverbatim and qualitative content analysis wasperformed using an iterative process of 3 codingrounds.Participants: 20 telehealth professionals.Setting: A telehealth service centre in the south ofGermany that provided care for 12 000 patients withchronic heart failure across Germany.Results: Non-video telehealth technology creates anatmosphere that fosters sharing of personalinformation and a non-judgemental attitude. Thisfacilitates the delivery of fair and equal healthcare. Acombination of a protocol-driven service structurealong with shared team and organisational valuesprovide a basis for establishing long-term healthcarerelationships. However, each contact between atelehealth professional and a patient has an uncertainoutcome and requires skilful negotiation of therelationship. Although care provision was personalised,there was scope to include the patients as ‘experts ontheir own illness’ to a greater extent as advocated byperson-centred care. Currently, provision of person-centred care is not sufficiently addressed in telehealthprofessional training.Conclusions: Telehealth offers a viable environmentfor the delivery of person-centred care for patients withlong-standing disease. Current telehealth trainingprogrammes may be enhanced by teaching person-centred care skills.

INTRODUCTIONThe growing number of patients with non-communicable, chronic disease and the con-stant increase in healthcare costs are globalchallenges. Health systems were originallydesigned to cure acute illness rather than toprovide prolonged caring, monitoring ormanagement of chronic diseases.1

Healthcare professionals require new skillsand technologies to manage the shifting

balance between acute care and the increas-ing numbers of patients living with a chronicdisease.2 E-Health solutions promise todeliver accessible, high-quality and cost-effective remote healthcare, and play acentral role in strategic healthcare planningworldwide.3–5 E-Health is an umbrella termfor all remote health information, communi-cation and care services that are deliveredand managed electronically or through infor-mation technology.6 The term ‘telehealth’ issituated within e-Health; more specifically:telehealth covers the remote delivery ofmedical and preventive care, or publichealth interventions via information tech-nologies.7 In the context of chronic disease,telehealth also aims to improve patients’ self-management skills. There are two principalmodes of telehealth delivery: video consult-ing and telephone (audio only) consulting.Video consulting enables the formation ofgood therapeutic alliances and producessimilar clinical outcomes as face-to-face con-sultations; however, the outcomes are notsuperior to telephone monitoring orsupport.8 9 Telephone support services in

Strengths and limitations of this study

▪ The present study may inform the current debateon integrating person-centred care principles intelehealth.

▪ Data collection through focus groups encouragedfree discussion and exchange of opinions tomitigate ‘socially desirable’ comments about tele-health or person-centred care.

▪ We could not exclude volunteer bias as our parti-cipants received financial compensation for timespent in focus groups. However, we were able torecruit a diverse sample with a broad range ofclinical and telehealth experience.

▪ Our sample was not designed to be statisticallyrepresentative, nor can we claim reaching datasaturation; however, our findings are consistentwith other research on protocol-driven, non-video telehealth technology.

Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750 1

Open Access Research

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

telehealth generally combine elements of patient educa-tion, telemonitoring of symptoms and communicationbetween healthcare staff and patients.9 Telehealth deliv-ery is primarily protocol-driven. Patient assessment andcommunication between the telehealth professional(THP) and the patient are often structured by question-generating computer software. The combination of tele-phone support and remote monitoring has proven bene-fits with studies finding a reduction in rehospitalisationrates and mortality. Patients also reported feeling saferand becoming more knowledgeable about theirdisease.10–12 Telecoaching services take a more patient-centred approach; these may also be protocol-drivenand facilitate monitoring and management of signs andsymptoms. Telecoaching services aim to affect healthbehaviour, increase patient empowerment and facilitategoal setting. A recent review concluded that telecoach-ing significantly improves health behaviour, health statusand self-efficacy in chronically ill patients.13 Despitethese benefits, the effect of telehealth services onpatients’ health-related quality of life and well-being islimited.11 13 14 A number of national strategies empha-sise the importance of tailoring telehealth services tothe needs of the individual patient.4 15 Although tele-health services are evolving towards an increased focuson the individual patient, the emphasis often remainson symptom monitoring and control. This focus situatesthe current telehealth approach in the biomedical para-digm as it neglects the individual’s personal experienceof illness in care planning and provision. Living with achronic disease profoundly affects a person’s whole life,including social, psychological, cultural and behaviouraldimensions. This personal and unique illness experiencecan only be captured through a patient’s narrativeaccount of living with a chronic disease, not throughsymptom monitoring.16 Moving towards a more compre-hensive and individualised service model that considersthe patients’ symptoms as well as their personal illnessexperiences, social environment, challenges, resourcesand disease progression may maximise the benefits oftelehealth for chronically ill patients. Person-centredcare (PCC) is a concept that redresses the focus ofhealthcare delivery. PCC aims to actively involve thepatient as an equal partner and expert on living with achronic illness in the care planning process.17 Patients’individual resources are activated to foster their ability toself-manage their illness. Research has demonstratedthat PCC reduces the experience of uncertainty inillness, improves self-efficacy and shortens hospital staysin chronically ill patients.18–21 Incorporating PCC princi-ples in telehealth services may offer a promising modelfor future healthcare provisions. Although shareddecision-making and egalitarian partnership are stillfairly new concepts in telehealth, a recent scopingreview concluded that PCC-based telehealth interven-tions have a positive impact on patients’ quality of lifeand health-related quality of life.22 However, PCC tele-health services often only partially integrate PCC

principles, thus leaving room for improvement.22

Currently, there is a dearth of knowledge on how moreegalitarian PCC relationships between healthcare profes-sionals and patients can be established, utilised andmaintained in telehealth to enable active patient partici-pation in decision-making and care planning. Our studyaddresses this knowledge gap by exploring telehealthrelationships with a view to create the potential to inte-grate PCC principles into the care delivery for patientswith chronic disease.

ObjectiveThe present study aimed to explore factors relevant tocreating and maintaining relationships between THPsand patients with chronic illness over distance, from aTHP perspective.

METHODSDesignThe present study used qualitative content analysis offour semistructured focus group interviews withTHPs. The explorative study is part of a larger researchprogramme (registration: http://www.isrctn.com/ISRCTN55562827) aimed at developing a telehealthservice for patients with chronic heart failure (CHF)and/or chronic obstructive pulmonary disease (COPD).We chose a qualitative design to explore how relation-ships in telehealth are established and maintained. Thefocus group interviews enabled interactive discussions,diversity, reflection and development of thoughts23

among our participants about the nature of telehealthrelationships.

SampleParticipants were recruited from the staff (70 staffmembers in total) of a service centre providing tele-health in Germany. The service centre management dis-tributed an information letter about the study and aninvitation to participate among the THPs and organisedthe focus group sessions. Twenty THPs agreed to takepart in the study. The telehealth service centre reim-bursed focus group participation as working time.Table 1 presents participants’ demographics.

SettingThe participants worked in a large telehealth servicecentre in the south of Germany that provides care andtelemonitoring for about 12 000 patients with CHFacross five German federal states. Patients report dailyon signs, symptoms and body weight. These data areautomatically transferred to the centre. To date, morethan 30 000 patients have participated in the telehealthprogramme. The telehealth service is covered by healthinsurance and is, therefore, free for patients. Patientsand THPs never meet face-to-face; telephone calls arethe exclusive means of communication. As more than95% of patients with CHF are diagnosed with at least

2 Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

one concomitant chronic disease, such as hypertension,diabetes mellitus, renal failure, COPD or atrial fibrilla-tion, the focus of the care concept is on multimorbidity.Care provision aims to strengthen self-management, pre-vention and early detection of deterioration throughdaily monitoring. The service also places strongemphasis on communication between patients andTHPs to ensure and accelerate decision-making. THPsreceive intensive initial and ongoing training, and per-formance monitoring to ensure a high standard of careprovision. Figure 1 outlines the telehealth servicecentre’s training structure.Unless patients prefer to be cared for by one THP, a

pool of three THPs is allocated to each patient so they

can benefit from a broad range of professional experi-ence. During the initial phone call, the THPs assessfactors such as the patient’s mobility, nutrition, social cir-cumstances and cognitive abilities as per the centre’sprotocol. Scheduled support calls, that also includeteaching units, then occur every 4–6 weeks, unless thepatient’s condition necessitates intervention. Patientsupport calls and symptom monitoring are structuredand protocol-driven. The THPs have a certain degree offreedom to deviate from the protocol, if necessary, forany reason. Figure 2 illustrates the telehealth serviceprovision.

Data collection and analysisThe four focus group interviews were semistructuredbased on an interview guide. Table 2 outlines the topicareas and key questions discussed during the focusgroups. The topic guide was developed based on areview of relevant literature and discussed among thepresent authors. Two of the authors (LA and AW) aretelehealth experts, and four are PCC experts (IE, BH,AW and LA).The focus group interviews were conducted on 3 and

4 June 2014. The interviews lasted between 1 h 13 minand 1 h 24 min. The telehealth service centre provideda private meeting room for the focus groups. Only theinterviewer and the participants were present during theinterviews. The first author (BH), a registered nurse andresearcher facilitated the interviews. All interviews weredigitally recorded. A professional typist transcribed theinterviews according to a transcription guide. To ensurethe transcript quality, the written record of the inter-views was checked against the digital recording and typo-graphical errors were corrected (BH). The transcriptswere managed with MAXQDA software for computer-assisted qualitative data analysis (VERBI GmbH, Berlin,Germany). The analysis was conducted in three cycles.During the first cycle, two interviews were coded itera-tively in an in vivo coding style to ground the analysiswith a THP perspective. The resulting coding frame wasreviewed by AW, and then revised by consensus betweenAW and BH. This coding frame was subsequently appliedto all interviews in a second cycle, and the codes wereagain organised and bracketed iteratively throughfocused coding into a final frame of codes and categor-ies. The categories were then condensed, connectedand interpreted into themes and subthemes. An audittrail of the code lists that emerged at different stages ofthe coding process was generated in MAXQDA. Thebase unit of analysis was the sentence. Sentences in asequence logically pertaining to particular ideas orthoughts were bracketed and coded as a single unit topreserve the original meaning. In contrast to otherqualitative methodologies, such as Grounded Theory orphenomenological hermeneutics, we interpreted theinterviews at a fairly superficial level, with languagetreated as ‘a vehicle of communication, not itself aninterpretive structure’.25 Basing interpretations on the

Figure 1 Training concepts for the telehealth centre:

establishing and maintaining specialist telehealth skills.

Table 1 Characteristics of focus group participants

(N=20)

Characteristics

Number of

participants

Gender

Female 19

Male 1

Qualification

Registered adult nurse 14

Geriatric nurse 1

Paediatric nurse 1

Paramedic 1

Missing data 3

Professional experience in clinical practice (years)

1–10 5

11–20 4

21–30 4

>30 3

Missing data 4

Professional experience in telehealth (years)

<1 2

1–5 12

6–10 3

Missing data 3

Role in telehealth

Telehealth professional with direct patient

contact

14

Telehealth professional+leadership role

(team leader, deputy team leader)

6

Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750 3

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

factual content of the interviews increases the transpar-ency of our interpretations and contributes to thestudy’s credibility and authenticity.25 26

ETHICAL CONSIDERATIONSThis present study was conducted during the preparatoryphase of a larger research programme (registration:

http://www.isrctn.com/ISRCTN55562827). The regionalethics committee at Gothenburg University approvedthe overall research programme. Since we conductedthe interview study in Germany, we also submitted thestudy protocol to the relevant German regional ethicscommittee for review. The German ethics committeedecided that there was no need for a formal application.Study participation was voluntary and participants wereadvised that they could withdraw at any point. All partici-pants gave informed written consent. All personal infor-mation was de-identified in the interview transcripts andother documentation. We cited direct quotes from parti-cipants. The ethical issues associated with the use ofdirect quotes in manuscripts reporting qualitativeresearch are complex. The deductive disclosure of parti-cipants and their potential stigmatisation are of particu-lar concern in studies that deal with sensitive topicsand/or include vulnerable participants. Our participantswere not vulnerable and the topic of our study was notsensitive. We did not ask or encourage participants todisclose or discuss intimate or private information orexperiences.27 The quotes we cited serve to support ourfindings.28 We chose quotes that reflected discussionconsensus and that were sufficiently general to precludeidentification of individual participants.29

RESULTSThree themes pertaining to establishing, developing andmaintaining relationships in telehealth emerged fromour analysis: (1) the telehealth setting: ‘challenges andfacilitators’; (2) ‘shared values’; and (3) ‘negotiating therelationship’. Themes (1) and (2) relate to the under-lying structure and culture of the telehealth environ-ment. Theme (3) describes the transitory nature of eachinteraction between THP and patient. Interview excerptsare included to support our findings.

Figure 2 Flowchart of telehealth

service provision. THP, telehealth

professional.

Table 2 The interview guide: topic areas and key

questions

Topic area

Key focus group discussion

questions

Patient—THP

interaction17▸ Where do you see the differences

in interaction with your patients

compared with face-to-face

interactions?

▸ How would you describe your first

call to the patient?

▸ What is important in telehealth

interaction with patients?

▸ What are your techniques to

connect with the patient?

▸ How do you win the patient’s

trust?

▸ How will you know that you have

established a connection with the

patient?

▸ How do you document the

interaction with the patient?

Professional

identity24▸ Which personal qualities are

particularly important in

telehealth?

▸ Which professional skills are

particularly important in

telehealth?

THP, telehealth professional.

4 Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

Theme 1: the telehealth setting: intrinsic challenges andfacilitatorsThis theme related to the particular challenges andfacilitators associated with the telehealth setting. TheTHPs emphasised how ‘not seeing’ a patient alteredthe personal and professional experience of careprovision.

Professional skills, knowledge and personal qualities‘Not-seeing’ complicated patient assessment. THPsrelied entirely on information verbalised by the patient,with no opportunity to support or authenticate thisthrough their own observations. THPs counterbalancedthis disadvantage with attentive listening and use ofsophisticated communication techniques. They reportedfocusing on the patient’s verbal expression anddescribed being highly sensitive to any changes in thetone and pitch of a patient’s voice. In addition toadvanced listening and communication skills, THPsemphasised the importance of extensive professionalclinical experience and medical knowledge, combinedwith personal qualities such as having a pleasant voiceand being open-minded.

Non-judgemental attitudeTHPs reported that ‘not seeing’ resulted in a less judge-mental attitude in both partners in the dyad. ‘Looks’ didnot influence feelings of sympathy or antipathy, and careprovision was perceived as being fairer. Combined withthe anonymity of telephone contact, the telehealthenvironment enabled patients to share even privateinformation:

IV1, THP 2: […] this anonymity, paradoxically, creates acertain closeness, because patients open up in a differentway. They tell you really intimate details of their lives andthat has something of a confessional character, becausethey cannot see you. […] they can get rid of theirworries and woes […].

Overall, THPs regarded the absence of visual clues intelehealth as an advantage and facilitator to relationshipbuilding.

Telehealth structureTelehealth calls are one-on-one appointments betweenTHPs and patients. The THPs appreciated this anddescribed this as a facilitator, particularly when com-pared with a hospital setting, where care staff must oftenrespond to numerous demands at any one time. The tel-ehealth service centre’s documentation protocol alsofacilitated relationship building, prompting THPs torecord extensive factual information about patients’lives, physical and psychological state and social situ-ation. This patient record enabled THPs to preparethemselves well for each support call.

Theme 2: shared team and organisational valuesTHPs across all focus groups spoke at length about thevalues they shared across the team.

Human dignityTHPs emphasised the importance of engaging with thepatient in a respectful manner and providing holisticpersonalised care. Specifically, this involved ‘meeting’patients where they were in terms of phase of life,needs, and cognitive and linguistic abilities. THPsreported they adapted their language to the patients’needs to maximise patients’ understanding of the infor-mation provided.

Enabling and autonomyIncreasing self-efficacy (ie, the ability to self-monitor andcommunicate signs and symptoms), and motivating andeducating the patient were considered to be important.All THPs believed that all the patients were capablepeople. They aspired to enable patients to unlock theirinnate potential by making suggestions or giving advice.However, they accepted that the final decisions aboutwhether to follow advice always remained with thepatient:

IV1, THP 1: I think the difference [between our tele-health service and other healthcare providers] is thatwith us, patients do not HAVE to [do certain things] andthey are not constantly being told what they CANNOTdo. […].

Prioritising the patient’s needsThe THPs reported prioritising an individual patient’sneeds over protocol adherence if they realised thatpatients were experiencing difficult life situations:

IV1, THP 4: If there is sometimes something very dra-matic [happening in the patient’s life] then we let theheart be the heart, and if there was a quarter of an hourscheduled [for the phone call] then we may take half anhour. This is an exception, but there are situations whenother things [than the heart condition] are more import-ant. And then we listen. […] When somebody has died[…]. I am not very interested [in hearing] if [thepatient’s] legs are swollen.

All of these values were supported by the telehealthservice centre’s organisational culture, which empow-ered THPs to deviate from the set protocol if they feltthis to be in the patient’s best interest. The THPs could,therefore, spend more time with a patient in need andless time with patients who did not require muchsupport.

Theme 3: negotiating the relationshipThe THPs stressed that relating to and connecting withpatients was essential to delivering telehealth. The rela-tionship between THPs and patients developed two tra-jectories: a ‘macrotrajectory’ and a ‘microtrajectory’.

Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750 5

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

During each support call, the patient and the THPestablished and negotiated a relationship on a microtra-jectory. Successful relationship building at this level, inaddition to daily telemonitoring, enabled the macrotra-jectory or the relationship between the service providerand patients over the course of several years.

The microtrajectoryThe THPs highlighted that the first telephone call wasan important milestone at both the microrelationshipand macrorelationship level. This was the stage wherepatients decided whether or not to join the programme.Gaining the patient’s trust in the service was thereforecrucial at this point. THPs indicated that while somepatients were interested and easy to engage with fromthe start, others were more doubtful. Some THPsreported that particularly sceptical patients challengedtheir professional knowledge. The THPs felt that themore they personally connected with a patient at thisearly stage, the better the long-term relationship thrived.However, all telephone calls—initial as well as regularsupport calls—required careful negotiation and thecourse of each interaction remained unpredictable. Eachinteraction could be influenced by the patient’s currentpersonal circumstances and mood or preferences. TheTHPs’ likened the relationship management to a dance.In this ‘dance’, the THPs constantly strived to establish aconnection with the patient. THPs reported adaptingtheir behaviour, choice of words and tone of voice towhat they felt worked best to engage with each patient.They had to be self-aware and manage their own emo-tional reaction to the patient. This could also entail dis-tancing themselves from highly emotional patients:

IV3, THP 4: […] you just stay calm and keep an openmind. I had the experience that when somebody grum-bles on the phone […] and they are initially aggressiveand just have to get rid of all this [aggression], then I letthem talk and talk and talk and at some point [thepatient says]: “that was stupid, wasn’t it? That did nothave anything to do with you” and then I say: “That’sokay, are you feeling better?”

THPs reported other signs of a successful connectionsuch as the patient being engaged, talking freely, askingquestions, thanking the THPs for the telephone call orasking for particular topics to be covered in the nextappointment. THPs also described feeling the connec-tion. Others described entering a flow in the dialogue andfeeling emotionally very close to the patient, or that thechemistry between them and the patient was just right.However, these feelings could be deceptive:

IV4, THP 3: There are […] patients, who say good-bye,make arrangements for the next call, ask for a topic.Then you know for certain, this was ok. And normally, Idon’t put down the receiver first, but I always wait untilthe patient hangs up. There are some [patients] whereyou have the feeling “this was a really great conversation”

and then your hear “Uhh, boah” [sighing or groaningnoises from the patient]. And then you know […]. Myperception was wrong […] Sometimes you get this reac-tion which is not positive. […].

The patient’s narrativeThe patient’s narrative is a personal story of their experi-ence with their illness. The THPs reported that listeningto the patient’s narrative was important for the relation-ship building. They encouraged patients to share theirstory if the account was directly related to the illness.When listening to the narrative, the THPs reportedactively picking up on ‘anchor words or phrases’ andusing these to guide the conversation. The overall aimof the conversation appeared to be to elicit factual infor-mation about the illness, and to provide suggestions andprofessional advice accordingly. THPs regarded them-selves as healthcare experts on the disease.These three themes describe the cornerstones for

establishing relationships between THPs and chronicallyill patients in the telehealth setting. Two themes relatedto the organisational structure and values that definethis particular setting, and one theme related to a moretransitory aspect of relationship building, characterisedby the constant creation and reaffirmation of the THP–patient relationship. All three themes enabled a ‘macro-trajectory’ or patients’ long-term relationships with thetelehealth service. The TPHs reported that with thepassing of time, patients grew accustomed to telephonecommunication with the THPs. Trust was maintainedand increased. Depending on cognitive and linguisticcapabilities, patients also acquired competencies, forexample, learnt medical terms to describe their disease,and associated signs and symptoms. At a macro level,interactional routines became established as patientswere socialised into the telehealth programme overtime. An overview of the final coding frame and inter-pretation into themes is set out in figure 3.

DISCUSSIONPrincipal findingsOur study explored the creation, development andmaintenance of telehealth relationships from a THP’sperspective. THPs reported that the non-video tele-health service environment created an atmosphere inwhich patients feel confident about sharing intimate orprivate health information. It also promoted a non-judgemental attitude that facilitated fair and equalhealthcare treatment for all individuals. However, patientassessment was hampered by the absence of visual clues.The combination of a protocol-driven service structure,and shared team and organisational values provided thefoundation for establishing long-term THP–patient rela-tionships, although each telephone contact with apatient remained unpredictable. THPs used their profes-sional and personal knowledge and skills to renegotiatethe relationship, and educate and assess the patient. The

6 Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

patient’s narrative was particularly important in elicitingfactual information about their condition. THPs sawthemselves as key people who solved problems and pro-vided advice to the patient. Protocol-driven, structuredtelephone support is the most common approach forproviding telehealth services to patients with CHF andeffective in reducing disease-related rehospitalisationand mortality.10 Patients reported being satisfied andfeeling cared for with regular telemonitoring.30

However, THPs have expressed concern that frequenttelemonitoring may lead to increased patient depend-ency on telehealth services.31 Two recent scoping reviewson chronic care management related to PCC found thatcurrent e-Health provision remains primarily focused ontelemonitoring, concluding that despite the currentinternational drive towards patient participation andshared decision-making in healthcare planning, patientsare still regarded as passive recipient of care in tele-health.22 32 Staff may also perceive a strictly protocol-driven approach to be at odds with carers’ professionalhumanistic and holistic values.24 22 30 32 The THPs inour study negotiated the proposed juxtapositionbetween protocol adherence and professional practicewith relative ease. They felt empowered to adapt the tele-health service centre protocol to the individual patient’sneeds. Unscripted, personalised telecoaching thatfocuses on patients’ personal priorities and motivationshas been shown to increase health behaviour and self-efficacy in chronically ill patients.12 However, neither tel-ecoaching nor telemonitoring lead to an increasedquality of life in patients with chronic disease.11 13 14

Overall, the THPs felt that the protocol-driven servicestructure combined with unscripted, personalised coach-ing, and their holistic values and professional skills pro-moted relationship building and care provision. Thisfinding highlights the importance of achieving a goodbalance between protocol-driven structures and holistic

care values in telehealth to successfully build relation-ships.13 However, the THPs, as healthcare experts, aimed toprovide the patient with information and support. Thecurrent format of telehealth monitoring and coachingaffirms that the patient is in the role of a more or lesspassive recipient of care.16 Including more unscriptedperson-centred, flexible approach that caters to the indi-vidual patients’ needs may increase the benefits gainedfrom telehealth services.There may be untapped potential in current practice

that could be exploited by fully integrating a PCCapproach, one that considers the patient as an expert ontheir disease and equal partner in shared careplanning.16 17 21

Strengths and limitationsHealthcare organisations worldwide are pushing theintegration of PCC principles in telehealth. How this willbe best achieved is a matter of current debate. Our find-ings may substantially inform this debate. The qualitativedesign is a particular strength of the present exploratorystudy as it uncovered the importance and possibility ofbalancing a protocol-driven service approach with a per-sonalised care approach through shared organisationalvalues. In our focus groups, we encouraged free discus-sion and exchange of opinions by using a format thatminimised ‘socially desirable’ comments about tele-health or PCC. Although the provision of financial com-pensation for time spent in focus groups may haveresulted in volunteer bias, it served as an incentive andhelped to recruit a diverse sample of THPs with a broadrange of clinical and telehealth experience. Our samplewas not designed to be statistically representative norcan we claim reaching data saturation; however, ourfindings that the telehealth environment fosters mutualrespect and sharing of personal information are

Figure 3 The final coding tree: codes, categories and themes. THP, telehealth professional.

Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750 7

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

consistent with previous research on protocol-driven,non-video telehealth technology.24 33

Implications for future researchOur results indicate that there is untapped potential inthe relationship between patients and THPs in the tele-health and telecoaching domain. Patients can be acti-vated and engaged to a greater extent in shareddecision-making and care planning. This requires com-munication and feedback loops between patients andTHPs, as well as awareness of enhanced power sharing,and staff and patient education.34 With the currentfocus on telemonitoring in telehealth, further researchshould focus on redressing this balance by developingsupplementary training elements for THPs to supportthe integration of PCC into telehealth. The approach ofthe Gothenburg Centre for Person-Centred Care(gPCC) comprises three processes: (1) initiating a part-nership through the patient narrative, (2) working thepartnership through shared decision-making, and (3)safeguarding the partnership by documenting thepatient narrative. This approach may be a suitable basisfor integrating PCC in telehealth.17 21

CONCLUSIONLong-term relationships between THPs and patients witha chronic illness can be created, developed and main-tained over a distance. A protocol-driven service struc-ture, and shared team and organisational values supportthis process. THPs’ professional skills and personal qual-ities in engaging with the patients’ narratives affirm therelationship during each telephone contact. However,there is potential to activate patients to become equalpartners in care planning and shared decision-making toa greater extent. Integrating PCC principles in telehealthand telemonitoring may maximise the potential of tele-health technology and enable patients with a chronicillness to manage their lives more independently.Extended theories on PCC delivery over a distance needto be developed in order to achieve this. PCC interactiontheories should also inform the development of trainingon person-centred communication, interaction and caredelivery to supplement and enrich current specialisttraining programmes for THPs.

Author affiliations1CAPHRI, School for Public Health and Primary Care, UM/CAPHRI,Maastricht, The Netherlands2The Gothenburg Centre for Person-Centred Care (GPCC), Institute of Healthand Care Sciences, Sahlgrenska Academy, University of Gothenburg,Gothenburg, Sweden3Health Care Systems GmbH (HCSG), Bavaria, Munich, Germany

Acknowledgements The authors are grateful to all the healthcareprofessionals who participated in this study for sharing their experiences andthoughts generously, and for engaging so enthusiastically in the focus groupdiscussions.

Contributors BH, AW, LA, SMS and IE contributed to the conception ordesign of the work. BH, AW, LA and IE contributed to the acquisition,

analysis, or interpretation of data; the drafting and critical revision of themanuscript; and to the provision of important intellectual content. BH, AW,LA, SMS and IE approved of the final version to be published and agreed tobe accountable for all aspects of the work in ensuring that questions relatedto the accuracy or integrity of any part of this manuscript are appropriatelyinvestigated and resolved.

Funding This research received no specific grant from any funding agency inthe public, commercial or not-for-profit sectors. It received non-financialsupport from the Gesellschaft für Patientenhilfe DGB mbh (GPH),Luise-Ullrich-Str. 4, 82031 Grünwald, Germany.

Competing interests None declared.

Patient consent Obtained.

Ethics approval Regional Ethical Review Board, Gothenburg, Sweden(application Nr 687-14). Bayerische Landesärztekammer (Regional ethicscommittee) Munich, Bavaria (no formal application required).

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

REFERENCES1. Potter SJ, McKinlay JB. From a relationship to encounter: an

examination of longitudinal and lateral dimensions in thedoctor-patient relationship. Soc Sci Med 2005;61:465–79.

2. World Health Organization. Preparing a health care workforce for the21st century. The challenge of chronic conditions. Geneva,Switzerland, 2005.

3. World Health Organization. mHealth: new horizons for healththrough mobile technologies: second global survey on eHealth.Geneva, Switzerland: World Health Organization, 2011.

4. Stroetmann K, Aartmann J, Stroetmann V, et al. European countrieson their journey towards national eHealth infrastructures. FinalEuropean progress report. Brussels, Belgium, 2011.

5. World Health Organization. National eHealth Strategy Toolkit.Geneva, Switzerland: World Health Organization, 2012.

6. Royal College of Nursing. eHealth: the future of health care. RoyalCollege of Nursing position statement. London, UK: Royal College ofNursing, 2012.

7. Doarn CR, Pruitt S, Jacobs J, et al. Federal efforts to define andadvance telehealth—a work in progress. Telemed J E Health2014;20:409–18.

8. Steel K, Cox D, Garry H. Therapeutic videoconferencinginterventions for the treatment of long-term conditions. J TelemedTelecare 2011;17:109–17.

9. Wootton R. Twenty years of telemedicine in chronic diseasemanagement—an evidence synthesis. J Telemed Telecare2012;18:211–20.

10. Inglis SC, Clark RA, McAlister FA, et al. Which components of heartfailure programmes are effective? A systematic review andmeta-analysis of the outcomes of structured telephone support ortelemonitoring as the primary component of chronic heart failuremanagement in 8323 patients: abridged Cochrane review. Eur JHeart Fail 2011;13:1028–40.

11. Kenealy TW, Parsons MJ, Rouse AP, et al. Telecare for diabetes,CHF or COPD: effect on quality of life, hospital use and costs. Arandomised controlled trial and qualitative evaluation. PLoS ONE2015;10:e0116188.

12. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on useof secondary care and mortality: findings from the Whole SystemDemonstrator cluster randomised trial. BMJ 2012;344:e3874.

13. Dennis SM, Harris M, Lloyd J, et al. Do people with existing chronicconditions benefit from telephone coaching? A rapid review. AustHealth Rev 2013;37:381–8.

14. Cartwright M, Hirani SP, Rixon L, et al. Effect of telehealth on qualityof life and psychological outcomes over 12 months (Whole SystemsDemonstrator telehealth questionnaire study): nested study of patientreported outcomes in a pragmatic, cluster randomised controlledtrial. BMJ 2013;346:f653.

8 Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from

15. APS Group Scotland. A National Telehealth and Telecare. Deliveryplan for Scotland to 2015. Driving improvement, integration andinnovation. Edinburgh, UK: Scottish Government by APS GroupScotland, Crown copyright 2012, 2012.

16. Engel GL. The need for a new medical model: a challenge forbiomedicine. Science 1977;196:129–36.

17. Ekman I, Swedberg K, Taft C, et al. Person-centered care—readyfor prime time. Eur J Cardiovasc Nurs 2011;10:248–51.

18. Dudas K, Olsson LE, Wolf A, et al. Uncertainty in illness amongpatients with chronic heart failure is less in person-centred care thanin usual care. Eur J Cardiovasc Nurs 2013;12:521–8.

19. Ekman I, Wolf A, Olsson LE, et al. Effects of person-centred care inpatients with chronic heart failure: the PCC-HF study. Eur Heart J2012;33:1112–19.

20. Fors A, Ekman I, Taft C, et al. Person-centred care after acutecoronary syndrome, from hospital to primary care—a randomisedcontrolled trial. Int J Cardiol 2015;187:693–9.

21. Ekman I, Hedman H, Swedberg K, et al. Commentary: Swedishinitiative on person centred care. BMJ 2015;350:h160.

22. Wildevuur SE, Simonse LW. Information and communicationtechnology–enabled person-centered care for the “big five” chronicconditions: scoping review. J Med Internet Res 2015;17.

23. Hennink P, Leavy P. Understanding focus group discussions.New York, USA: Oxford University Press, 2014.

24. Snelgrove SR. Nursing work in NHS Direct: constructing anursing identity in the call-centre environment. Nurs Inq 2009;16:355–65.

25. Sandelowski M. Whatever happened to qualitative description? ResNurs Health 2000;23:334–40.

26. Whittemore R, Chase S, Mandle C. Pearls, pith, and provocation.Validity in qualitative research. Qual Health Res 2001;11:522–37.

27. Kaiser K. Protecting respondent confidentiality in qualitativeresearch. Qual Health Res 2009;19(11):1632–41.

28. Corden A, Sainsbury R. Using verbatim quotations in reportingqualitative social research: Researchers’ views. 2006. https://www.york.ac.uk/inst/spru/pubs/pdf/verbquotresearch.pdf (accessed 18 Oct2015).

29. Hollander J. The social contexts of focus groups. J ContempEthnogr 2004;33:602–37.

30. Riley JP, Gabe JP, Cowie MR. Does telemonitoring in heart failureempower patients for self-care? A qualitative study. J Clin Nurs2013;22:2444–55.

31. Fairbrother P, Ure J, Hanley J, et al. Telemonitoring for chronic heartfailure: the views of patients and healthcare professionals—aqualitative study. J Clin Nurs 2014;23:132–44.

32. Gammon D, Berntsen GK, Koricho AT, et al. The chronic care modeland technological research and innovation: a scoping review at thecrossroads. J Med Internet Res 2015;17:e25.

33. Oudshoorn N. Telecare technologies and the transformation ofhealthcare. New York, USA: Palgrave MacMillan, 2011.

34. Longtin Y, Sax H, Leape LL, et al. Patient participation: currentknowledge and applicability to patient safety. Mayo Clin Proc2010;85:53–62.

Heckemann B, et al. BMJ Open 2016;6:e009750. doi:10.1136/bmjopen-2015-009750 9

Open Access

on June 14, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-009750 on 2 March 2016. D

ownloaded from