Telemedicine: What’s the problem and how to increase adoption?

Every U.S. citizen has a vested interest and an opinion about the quality and effectiveness of healthcare delivery, a $3.8 trillion industry with rapidly escalating costs.

The fastest-growing industry in healthcare is telemedicine, which is now used in over 50% of the hospitals in the U.S. to promote remote access to healthcare. Examples range from tele-surgery to tele-emergency care to tele-psychiatry. The reasons for telemedicine abound. It allows specialized care to be distributed from a central hub to a rural location or an underserved population, efficiently and at lower costs.  For instance, in 2012, the Veterans Administration (VA) documented over 1.5 million telehealth sessions, for over 35% of veterans.

Problem statement and opportunity

The primary problem with telemedicine is low user adoption rates because many people resist organizational change. The result is massive waste that can be reduced.   Telemedicine technology and processes exist. However, organizational readiness for telemedicine results from two variables: 1) ability to change, and 2) motivation to change. The innovation diffusion curve (see Figure 1) demonstrates an immediate opportunity for telemedicine initiatives to move from the early adopter phase to the majorities.

Organizational readiness for telemedicine can be measured.   The key variables for organizational readiness include 1) executive sponsors who champion the ability and need to change, 2) buying agents convinced by case studies or ROI data of the economic value for the change, and 3) consumers driven by a compelling need for effective, inexpensive health care outcomes. The need for organizational leadership innovations in telemedicine programs is immediate.

DOI curve

Figure 1: The innovation diffusion curve (in Rogers (2003) Diffusions of Innovation)

Unique opportunity:  Tennessee

Although resistance to telemedicine is a global problem, we have a unique opportunity to provide a solution from Tennessee. Described as the “Global Center of Healthcare,” Nashville, TN has over 400 healthcare companies, spawned from Healthcare Corporation of America (HCA). On January 1, 2015, Tennessee became the 21st state to enact “telemedicine parity” legislation requiring that insurers reimburse licensed health care providers for services delivered remotely just as they would for in-person visits. On February 15, 2015 Tennessee added law stating that telehealth providers will be held to the same level of care as direct care providers (SB 1223). That law “opened the door” for telemedicine services to be delivered remotely, at lower cost, to rural minorities in Tennessee. We are in the right time at the right place to lead innovation in telemedicine.

Sadly, there is resistance to telemedicine from consumers and administrators who do not trust the government, or the technology, or the financial benefits. A telemedicine visit may cost $50 and take 10 minutes (e.g. MD Live, Teladoc); an ER visit may cost $150 and take 3 hours; a hospital visit may cost $15,000 and take 3 days. Telemedicine has demonstrated a 10X cost savings. Unless, of course, there is organizational resistance to change, in which case telemedicine is a waste of time and resources.

One administrator said, “We have 3 telemedicine kiosks sitting in a storage room, hidden by sheets. The vendor who provided them no longer exists.   The technology may be extraordinary, but I cannot get my physicians and nurses to use it.” His experience represents hundreds of wasteful healthcare initiatives.

What can you do to increase adoption of telemedicine? 

Book Review of Triggers, by Marshall Goldsmith (Crown Business Books, 2015)

(Disclosure: I am a fan of Marshall Goldsmith because he is an enthusiastic role model for countless executive coaches. When I shook his hand at an event hosted by the Center for Creative Leadership, I told him so. And when I was given four copies of this book to distribute to our largest CoachSource clients, I told them something favorable. Marshall Goldsmith has celebratory cachet as a thinker and a champion.)


I wanted to love this book, but it fell short.


Triggers can be defined as “any stimulus that defines our behavior.” That broad definition enables Goldsmith to go beyond Skinnerian behaviorism, or beyond antecedent-behavior-consequence, or Duhigg’s cue-routine-reward model.   The “Circle of Engagement” model includes five steps: trigger-impulse-awareness-choice-behavior. The primary focus of the book is to “help others achieve lasting positive change.”


Structures help us define individual behavioral change. Goldsmith defines three structures: the AIWATT question, the “Six Engaging Questions” and the “Wheel of Change.


  1. The AIWATT question can increase engagement. Ask yourself, “Am I willing, at this time, to make the investment required, to make a positive difference on this topic?” Am I willing at this time… is the short version.


  1. The six “Engaging Questions” can be useful early in a coaching engagement, and when measuring behavioral trends. The questions are: 1. Did I do my best to set clear goals? 2. Did I do my best to make progress toward my goals? 3. Did I do my best to find meaning? 4. Did I do my best to build positive relationships? 6. Did I do my best to be fully engaged?


  1. The Wheel of Change can be described using two axis or four spokes on a wheel. One axis is the Positive to Negative axis, which “tracks the elements that either help us or hold us back.” The second axis is the Change or Keep axis, which “tracks the elements that we determine to change or keep in the future.” This descriptive model encourages clients to explore what they may need to create, eliminate, accept or preserve in order to achieve their desired behavior change.


The remaining content includes anecdotes from Goldsmith’s broad client base. His charming, self-effacing style often made me smile. The inclusion of the Buddhist anecdote reminding us that anger is always directed at “an empty boat” is a perfect reminder to stay focused on our internal locus of control in the moment. The resounding feeling I had is that the book made me feel good, consider using some of these structures, and then wonder “Now what?”


There are no citations of published works in this book. However, an emerging body of academic research does exist. Positive psychology provides the theoretical construct that the profession of executive coaching sorely needs. There is abundant research in well-being. Seminal leaders include Richard Boyatzis’ Intentional Change Model and studies using neurobiology, Mihaly Csikszentmihalyi’s Flow and optimal experience research, and Martin Seligman’s work in PERMA (positive emotion, engagement, relationships, meaning and purpose, and accomplishment.)   These are evidence-based thought leaders, with broad following, who are not referenced by Marshall Goldsmith. That fact makes me wonder, why not?


According to the International Coaching Federation, there are now some 50,000 professional coaches in a $7 billion industry with little consistency. (Disclosure: I have been certified at the ICF-PCC level since 2006.) The Conference Board 2014 survey, from 142 companies, defines external executive coaches compensation ranging from $600-200/ hour depending upon the size of the company, developmental needs of the leader, and seniority. The average investment for 6 months and 40-45 hours is $25,000. The 2014 ICF survey states that the average salary is $214/hour. The market realities and financial value of executive coaching are significant.


My experience of countless “coaches” is that the profession sorely needs a) a scientific evidence-based backbone and b) a theoretical backbone.   Without such theory, science, and applications, the profession of executive coaching is at risk.


In hindsight, I realize that I wanted Marshall Goldsmith to provide some leadership or insight into these aspects of executive coaching. Marshall Goldsmith’s book Triggers does not address any of these academic, social and market realities. Hence it fell short of what I had expected. I can imagine him chuckling and retorting, “OK, so what are you going to do that would make you happier?”


Perhaps that is the subject for a different blog.


Call me if you’d like to discuss this book?

How to change behavior in three steps

3 Steps

Thankfully, as a species and as individuals, we know that humans adapt to environmental stimuli.

Behavior changes when we (1) modify the cues (e.g. positive or negative triggers), then

(2) we change the routine (e.g. gestalt, patterns) and

(3) we include regular rewards (e.g. self-care, executive coaching and consulting)

As an example, when you (1) place a white placement at a table, and sit down to eat no more than three times a day (cue), and (2) use a 5” diameter plate that has a smaller serving size than most American restaurants, and refuse to snack (routine), then (3) your reward will be weight loss or weight management.

Same with any behavior change.


Imagine that you are stuck in an undesirable habit, and that you “know you need” some behavior change.  For instance, imagine that you desire to build resilience.

Resilience can be defined as “the capacity to adapt successfully in the presence of risk and adversity.”


As a second example, when you pause for 5 seconds before saying or doing your response (cue), using a physical trigger or new activity to anchor the new routine, such as using one hand to pull on each finger of your other hand (routine), then your reward may be guidance from your prefrontal cortex that informs you to reply in some career-enhancing manner.  You adapt successfully and build more resilience.  Get the idea?

Individual behavior changes faster when others reward us.  Find a coach or an accountability partner.  You do not need to hire an executive coach or consultant to practice behavior change.


Call Doug Gray, PCC, today at 615.905.1892.


What are you waiting for?

How to diagnose physician resilience

Physicians with resilience have:

  • Increased career satisfaction
  • Higher personal life satisfaction
  • Enhanced performance and efficacy
  • Engagement with lifelong learning
  • Skills that may be modeled and directly transferable to patients (e.g., CBT)

Thankfully, resilience can be taught and developed.

Resiliency can be defined as “the capacity to adapt successfully in the presence of risk and adversity.”


Take this quick self diagnosis for burnout and resiliency:

Take a moment to write down where you think you are on a scale of 1 (low) to 10 (high) on these two measures. Note that burnout and resiliency are directly related and inversely related. Like any coin with two sides…

A self-diagnostic question is “How do you know if you are avoiding burnout behaviors?”

An organizational-diagnostic question is to ask your team if they have noticed you being less compassionate, hopeful and caring lately?

Or if you are daring, ask your team if they have noticed you being more abrupt, judgmental, or impatient lately?

(We are often hired to assess the degree of burnout or resiliency in a practice group.)

My experience is that these bullets are 5 reasons for you to do some work.  “Physician heal thyself” is axiomatic.   As a species, we need to make more anabolic choices than catabolic choices.

CBT is cognitive behavioral therapy, a psychological process that recognizes choice, personal strengths, and includes reqular behavioral feedback.

I hire a dentist when I need dental work; why wouldn’t you hire a psychologist when you need to develop resilience for your self or your team?