Targeting Patients’ Cognitive Load for Telehealth Video Visits Through Student-Delivered Helping Sessions at a United States Federally Qualified Health Center: Equity-Focused, Mixed Methods Pilot Intervention Study

Abstract

Background The task complexity involved in connecting to telehealth video visits may disproportionately impact health care access in populations already experiencing inequities. Human intermediaries can be a strategy for addressing health care access disparities by acting as technology helpers to reduce the cognitive load demands required to learn and use patient-facing telehealth technologies. Objective We conducted a cognitive load theory–informed pilot intervention involving warm accompaniment telehealth helping sessions with patients at a Federally Qualified Health Center (FQHC). We demonstrate how to design and report recruitment methods, reach, delivery process, and the preliminary impact of a novel equity-focused intervention. Methods Early into the COVID-19 pandemic a telehealth helping session was offered to patients at FQHC via phone. Graduate students led the sessions on conducting a telehealth video test run or helping with patient portal log-in. They systematically recorded their recruitment efforts, intervention observations, and daily reflection notes. Following the intervention, we asked the intervention participants to participate in an interview and all patients who had telehealth visits during and 4 weeks before and after the intervention period to complete a survey. Electronic health records were reviewed to assess telehealth visit format changes. Descriptive and inferential statistical analyses of the recruitment records, electronic health record data, and surveys were performed. Through integrative analysis, we developed process-related themes and recommendations for future equity-focused telehealth interventions. Results Of the 239 eligible patients, 34 (14.2%) completed the intervention and 3 (1.2%) completed subsequent interviews. The intervention participants who completed the survey (n=15) had lower education and less technological experience than the nonintervention survey participants (n=113). We identified 3 helping strategies for cognitive load reduction: providing step-by-step guidance for configuring and learning, building rapport to create confidence while problem-solving, and being on the same page to counter informational distractions. Intervention participants reported increased understanding but found that learning the video visit software was more difficult than nonintervention participants. A comparison of visit experiences did not find differences in difficulty (cognitive load measure) using telehealth-related technologies, changes to visit modality, or reported technical problems during the visit. However, the intervention participants were significantly less satisfied with the video visits. Conclusions Although a limited number of people participated in the intervention, it may have reached individuals more likely to need technology assistance. We postulate that significant differences between intervention and nonintervention participants were rooted in baseline differences between the groups’ education level, technology experience, and technology use frequency; however, small sample sizes limit conclusions. The barriers encountered during the intervention suggest that patients at FQHC may require both improved access to web-based technologies and human intermediary support to make telehealth video visits feasible. Future large, randomized, equity-focused studies should investigate blended strategies to facilitate video visit access.

On validating a generic camera‐based blink detection system for cognitive load assessment

“…Likewise, in manufacturing wherein psychological are responsible for a higher risk of work-related injuries [3,58], it is possible that inexpensive solutions like the one proposed here may allow for the early detection of high cognitive load in workers, especially for the jobs requiring completing repetitive workstation tasks. In telehealth, where both the user and the healthcare provider are at a high risk of experiencing mental stress due to information overload, technological barriers, or distractions [59,60], leveraging camera technology that is already part of telehealth's delivery methods may be a possible solution to reduce the risk of cognitive overload.…”

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“…Strategies to center marginalized voices in analyses include continuously revisiting data [87,88] or regular analytic team discussions [87]. In Project Simplify, we used a form with questions to prompt research assistants to write daily reflections throughout an intervention, which we analyzed thematically [38]. Other approaches include using templates to prompt researchers' assumptions [87].…”

“…Such approaches may favor diversity in study samples [37]. For Project Simplify, we piloted an intervention to support telehealth video visits [38]. Based on advice from our FQHC partner, we first attempted to reach potential recruits by phone and made calls through a clinic phone number.…”

“…Based on advice from our FQHC partner, we first attempted to reach potential recruits by phone and made calls through a clinic phone number. As desired, with this approach, people who participated in the intervention had less internet experience and formal education than other FQHC patients [38].…”

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“…A cross-sectional study of patients at an urban academic hospital after the implementation of a telehealth program found that increasing age was associated with lower electronic health literacy [28]. Another study of patients in an outpatient clinic found those with poor internet access or inadequate hardware, low health literacy, and those who are deaf, hard of hearing, or visually impaired may not benefit, and may even be harmed by a practice's focus on delivering healthcare via telemedicine [29]. Payer and insurer limitations to telehealth participation remain barriers to care as well.…”