Our company had to figure out why user adoption was so low with video consultations compared to phone consultations. We had a lot of resources invested in developing our own video solution and yet only 3% off all consultation were done over video.
Many assumptions were made by our leadership. Among these, the assumption that “women don’t like to use video conferencing when they’re sick” caught my attention as it resonated with comments made by a group of women in a focus group earlier that year. I used this assumption as a primary angle to look into the problem. Women accounted for almost 2/3 of our users.
In the early stage of discovery I found that 70% of our users had never seen our online products. We had a great phone infrastructure able to efficiently handle large amounts of consultation requests and account creation, and they could shield a patient from doing anything online. So 70% of our users didn't know anything about our online services! And no one in the Csuite had yet made this observation!
We launched a user survey using Usertesting.com with 120 respondents. We created a series of scenarios meant to question the most dominant assumptions regarding low adoption of the video medium. We paid particular attention to gender bias regarding the choice of communication mediums.
fear of privacy vs. need for Sincerity
We discovered that women, if thinking only abstractly of using a telehealth service, were considerably more likely to negatively perceive video conferencing due to the medium’s privacy stigma. But the perception radically changed when the telehealth service was needed. In fact, the demand for video is similar between men and women when they’re feeling sick, both found video to be a more sincere medium than the phone.
Trust me, I'm sick
We also discovered a correlation between an absence from work due to illness and the need for a truthful interaction with a doctor to verify that illness (in the form of a doctor’s note). This required a visual interaction and therefore made video conferencing more desirable.
A problem of demand and supply
Finally, we established that demand for video consultation was considerably greater than the supply, half of the respondents were likely to choose video consultation, yet video consultation were accounting for about 15%. Doctors had greater incentives for offering phone visits than video visits -- the primary reason for this was that video visits were likely to fail due to technical problems.
Then we inquired about the way patient discovered our services, a majority of them learned about it through leaflets, often posted in the break room. The leaflet features gave a choice: a phone number or a relatively long URL. Most people called the first time and their account was handled by our customer service. They had no incentives to use our online products and didn't know about our video consultations.
It was necessary to rethink doctor incentives, we couldn't just pay them per consultation or a phone consultation would remain the primary medium. We also suggested to improve mobility between mediums: we had to push people online, anyone who calls needed to have an easy way to jump online and have a video consultation.
We also recommended working on a new set of messages targeting women that showed a phone interaction as a primary medium for online visits; this would address their initial negative perception of a telehealth industry which solely uses teleconferencing allegories to advertise their services.
And finally we needed to capitalize on doctors notes justifying an absence at work - a powerful incentive to using a telehealth application!
A Problem with Video Consultation Adoption
With our telehealth service, a patient could request a medical consultation by dialing a phone number or by getting online - via web or mobile app - to make a request. Patients who were online could choose between a phone consultation and a video consultation.
Phone consultations were overwhelmingly popular. In fact, at the time, only 3% of all consultations were performed through video. However, a recent marketing user survey noted we had a considerably higher net promoter score after video consultations than after phone consultations. Yet, considering the low utilization of the medium there was serious concerns about the large resources dedicated to building a proprietary video platform.
There was among the leadership a large array of opinions to explain the low utilization numbers for video visits. One assumption in particular caught my attention: women don’t want to be seen when they are sick. But women accounted for more than 60% of our active users, and would use the service at least 25% more than men. About two thirds of all visits were with female users, so a negative perception of the video medium could indeed have a significant impact on utilization.
I proposed to go find out with more certainty an explanation for these low utilization figure and provide medium and long term solutions based on the findings.
The Elephant In The Room:
Only 1 Out of 4 Users Can Choose Video
As I started to look into the matter, I realized that no one in the company had yet factored in that the choice between phone or video was only available to users who had claimed their online account. Users who dialed in for a visit didn’t have an online account, so they couldn’t have a video visit - and dialing users accounted for 70% of all registered users.
This split between dialing users and online users was an important point because a sizable aspect of the company’s revenue strategy depended on online product development. In fact, a large proportion of the company’s budget was about online product development. But the “old-fashioned” call center was literally carrying utilization. It the call center was completely overlooked as an area of development and neither Product nor Design were remotely involved with it.
To me, our problem was about dial in requests Vs online requests. We needed to understand why our users choose one or the other. And because women accounted for a large majority of our users, we needed to check if video was a deterrent to online utilization.
We needed to test our assumptions and collect qualitative data. So we put a test together and used Usertesting.com to collect user feedback.
The test was structurally simple: we presented our product, introduced a scenario - a reason and a context to use the service -, then provided a choice between phone or video, and finally asked the respondent to justify the choice they made.
We avoided describing the product with “see” [a doctor] or “talk” [to a doctor] to prevent influencing the subsequent choice.
We developed 4 scenarios. 3 of them were based on typical use cases which were based on an array of customer feedback and previous studies conducted by Marketing, Product, and Design:
1 - Benchmark: in the first scenario we purposely omitted presenting a context in which our telehealth application would be used. Our intent was to let respondents express their own perceptions, projections and expectations towards having a remote consultation via video or phone.
2 - Sick at home: our scenario described one of the most common reasons for a visit. The respondent would imagine waking up at home with strong cold symptoms and then decide to seek out a doctor. Our intent was to verify the assumption that women would be uncomfortable using video in the privacy of their home.
3 - Sick at work: the scenario described emerging symptoms for gastroenteritis while at work in an office. Our intent was to verify assumptions regarding choices of communication medium while experiencing a lack of privacy.
4 - Known Provider: the scenario described a post surgery check-in a few weeks after the procedure. It implied that the patients knew the provider. We wanted to verify how familiarity would affect the choice.
We ran a pre-test with 7 respondents to iron out the questions. Then we ran each of the 4 scenarios in batches of 20 respondents. Each respondent would participate in only one scenario. Each batch had a demographic distribution* representative of our user base (*gender and age). We weeded out respondents who are familiar with telehealth services (only 2 out of 80).
Women Are Initially 4 Times less likely To Use Video
When no actual use case was defined (scenario 1) we found that women were 4 times less likely than men to want a video consultation .
Female respondents overwhelmly had negative assumptions about online video chat rooms and webcams for video consultations. They generally found the medium intrusive, and when sick, their notions of self-image were challenged.
On the other hand, male respondents generally preferred a face-to-face interaction because it increased their perception of service quality: the provider will be able to make a better diagnosis but they would also be able to verify that the doctor is trustworthy.
Sick at home:
Everyone Prefers Video Consultations
But in scenario 2 (sick at home) a majority of female respondents chose video, and chose video in the same proportion as men. This was in-validating our initial assumption that women don’t want to be seen when they are sick.
Women justified their choice by saying that they believed video would more appropriately convey how they they were feeling to the doctor.
It’s interesting to note that respondents’ answers also implied that being seen - via video - engaged the patient’s desire to prove they were actually sick so they could justify an absence from work. So, in contrast, voice consultations was perceived less truthful. When the stakes are higher a visual interaction trumps any issues a user could initially have with privacy/personal space or self image.
Finding a Private Space For a Consultation
Is Hard at Work
Scenario 3 validated that privacy in a work environment is truly an issue, and that a large majority of users - regardless of gender - prefered a phone call which would make their condition less obvious to others. We must note that the condition we described could be seen as more embarrassing than other conditions, based on our knowledge from previous surveys that the condition is in itself a factor of medium choice.
Familiarity With Known Providers
is conducive to video interactions
Finally, scenario 4 validated that when a patient already knows the doctor, they overwhelmingly prefer video consultations.
Low Odds For Online Usage
Consumer adoption of telehealth products is very likely affected by women’s initial negative perception of the video medium. The “privacy stigma” attached to the video medium is detrimental to a telehealth industry which almost exclusively uses images of patients talking to a doctor via video conferencing on mobile devices or computers. Our company was no exception, despite the fact that 97% of all consultations were happening via phone. Despite this, we still used teleconferencing as the main visual allegory for telehealth.
It’s also important to consider that our services were largely distributed as an employee benefit, and people would receive promotional material featuring images of teleconferencing. The material prominently featured a phone number to call, then a rather long custom URL. Needless to say, calling was easier than logging in online or seeking out the online application.
So it was essential to attempt to change the message conveyed to people who were eligible for our service but who were not yet users. We needed to recognize the initial negative assumption women had towards video and change the iconography that illustrated our marketing material.
Video In High Demand and Poor Supply
The study showed that a majority of respondents exposed to a typical scenario would prefer video - regardless of gender. If we combined the 4 scenarios there was almost a 60% bias towards video. So our video utilization figure (13% of users who had a choice of medium) was considerably below the hypothetical demand. We could confidently say we had an issue with video consultation supply.
Looking into the the supply issues we could make a strong case that it was caused by a poor incentive model to pay doctors for the consultations they perform and a bare bone consultation allocation workflow.
The incentive model would not compensate doctor adequately for the challenges and the uncertainties related to a video consultation (which would often be technical issues). And the consultation allocation workflow would let doctors cherrypick consultation they could process the quickest based on the medium used and the nature of the request. Consequently doctors as well as patients had higher incentives to use the phone because it was more reliable and yielded shorter interactions and therefore more income.
The company was aware of the instability of the third party video technology and was developing it's own. But a more stable technology wouldn’t change the fact that a face-to-face interaction implies more complex behaviors which would increase user satisfaction but also the length of consultations and therefore diminish doctor's income.
We needed to make doctors accept more video consultations, and to do so, we needed to get involved in redesigning their incentive system.
Doctor’s Note and Developing Online Clientele
The study incidentally revealed that users were more likely to engage with the service if they considered it for justifying a sick day. And since a doctor’s note could only be delivered online, increasing awareness of this feature would most likely be an incentive to increase online utilization. This could be communicated to patients who used the call center to request a visit.
The study also confirmed that patients who saw a doctor once would see the same doctor again if the experience was satisfying. So we suggested developing the patient doctor-relationship to increase satisfaction and engagement. A patient who wished to see the same doctor again is made aware of the doctor’s online schedule. Doctors are given tools to keep in touch with their patient, and the company mentions the doctor in targeted patient engagement events.
A Better Message
We established that our primary users - women - had a changing perception of our telehealth service based on the context in which they would use a telehealth service. Their initial resistance to the video medium was detrimental to online usage. But with a change in engagement strategies - with marketing material and solutions facilitating a switch to the web and the mobile app - we would likely be able to increase utilization and satisfaction.
Bridging the gap between dialing in and online EXPERIENCE
We strongly established a demand for video consultations, and therefore online activity. So bridging the gap between a phone call experience and an online experience was essential. We needed to develop strategies that would remove the boundaries between a call center only experience and an online experience. To do so we suggested to look into developing a parallel SMS channel that would lead phone only user towards the online experience and also serve as a 2 steps identification system providing a temporary password to access the online experience.
Pushing doctor's notes to increase online and video utilization
We understood that the convenience of telehealth regarding issues with missing work for medical reason could be exploited to induce users to register to their online account and engage with video consultations. So we recommended to prioritize the development of features around the doctor's note and proposed to work on streamlining its availability for every medium.
Increasing the video availability
by designing better incentives for doctors
We made suggestions for developing features and proposed to “gamify” the incentive system so providers would maintain a set of goals to maximize their income. The goals were based on a limited range of metrics we believed could increase patient satisfaction and also increase providers’ earnings while building a better consultation allocation system that would prevent more "difficult" consultation requests to remain stranded in the queue.
The study strongly established a demand for video and it helped legitimizing further the ongoing - and resource draining - development of an in-house video platform. But we demonstrated that a better video technology wouldn't resolve low online utilization figures and slow moving net promoter scores. In the current situation "dial phones" interactions were a utilization vacuum preventing to develop added value with online features.
We proposed to coordinate a joined effort through close collaboration with the call center and marketing in order to test a change in message, create bridges between the phone and the online experience. We also proposed to work with the clinical comity to look into a incentive/performance program able to drive video utilization up among providers.
Despite an overall good receptions of our findings and suggestions the company wasn't yet structured to organize a cross department design initiative. More efforts needed to be made to create an appropriate "design-thinking" environment.