How would your practice's leadership react if a physician or staff member said, “I'd like to start teleworking one day a week. I'll be more productive without the distractions of the office.” In this time of physician and staff shortages, it might be hard to say no. (See “Hybrid Schedules Are Key to Physician Recruitment and Retention.") There also may be plenty of reasons to say yes. Many primary care tasks, clinical and administrative, can be performed virtually,¹ and allowing physicians and staff to work remotely at least part of the time could aid recruitment and retention, as well as have other benefits for your practice. In this article, we provide guidance on what to consider before making the decision, as well as practical tips for implementing telework.

WHAT ARE THE PROS AND CONS OF TELEWORK?

Numerous studies have examined the positives and negatives of telework (see a summary below). Many workers believe that telework makes them more productive, in part because they can avoid the daily commute and distractions of the office.² Employers that are more supportive of remote work have less voluntary turnover and decreased absenteeism.³ Telework allows for flexible scheduling that may improve employees' work-life balance and reduce “work-family conflict.”⁴ Additionally, the abrupt rise in telemedicine during the COVID-19 pandemic showed that it can help maintain access to care when face-to-face contact threatens the health of both patients and staff (see “Telehealth reimbursement”).

But there are potential drawbacks. For employers, these could include technology costs and reduced ability to enforce professional standards (e.g., dress code or background when the employee is on screen). For employees, full-time remote work is associated with fewer bonuses and less career advancement⁵ compared with non-remote or “hybrid” work, where employees work outside the office only part of the week. There is also some evidence that working from home can increase work-family conflicts, especially if work hours and home responsibilities are not clearly defined.⁶

WHAT WORK CAN BE ACCOMPLISHED VIA TELEWORK?

Practices need to analyze what work can be done remotely and whether their technology is sufficient to support it. Examples of primary care clinic work that can be done remotely include phone triage, nurse follow-up calls, scheduling, billing, tele-medicine via phone or video, and clinician administrative time (such as education, online training, chart completion, test result follow up, and quality improvement project work).

The technology infrastructure to promote telework must include a secure way to access appropriate HIPAA-compliant charting, scheduling, and billing software when off site. For most practices, the EHR is already used in this way, as the average physician spends nearly 90 minutes per day working at home, outside of normal office hours, on charting and related tasks.⁷

IS THERE A PROBLEM THAT TELEWORK WILL SOLVE?

If your worksite has limited parking or limited space to work in, then allowing some employees to work off site can reduce space constraints. If you are short on staff, offering telework may help with recruitment, especially in areas where a high percentage of the potential applicant pool would face a long commute. Offering even one day of telework per week gives you a recruiting advantage over employers who don't. It could also help you retain current employees by promoting staff well-being. Less time spent commuting and the “mental break” of working in a different setting episodically could help prevent burnout.

WHO CAN TELEWORK?

This will be dictated in part by the type of work your practice decides can be done remotely. Efficiency and scope of practice boundaries may make you want to limit that work to only certain professions. Or you may decide that every position in your practice can do some work remotely. Once you've identified which professions can telework in your practice, the next step is to determine if everyone in that role will be allowed to telework or whether individuals will be chosen based on seniority, last performance review, need, or other criteria.

You can offer telework on a voluntarily basis, or assign it for certain roles and then allow staff to opt out if they prefer to come into the clinic or don't have the necessary resources (e.g., high-speed internet access) at home. Depending on the profession, union or other labor groups may have to be involved in this process.

DO STAFF MEMBERS NEED ANY NEW SKILLS FOR TELEWORK?

Depending on the technology you use and the type of work to be done remotely, practices may have to plan for some training before instituting telework. For example, staff may need to be trained in how to access the file server remotely or how to use the chosen video conferencing platform. (For resources to help with telework training, see below.)

Practices may also need to train staff on what the expectations are for telework.⁸

WHAT ARE THE EXPECTATIONS FOR TELEWORKING?

Practices should create a written agreement or contract that outlines expectations for teleworking and have the employee sign it. The document should address issues such as the following:

• What is the agreed-upon schedule?

• Does the employee have a place to work with auditory and visual privacy? (This is especially important for employees working with HIPAA-protected health information or financial billing information.)

• Does the employee have adequate, reliable internet access?

• Is the employee expected to turn their camera on for meetings?

• Is the dress code on camera the same as it would be on site?

• When the employee is on camera, is a specific background required?

• Are staff members allowed to take documents or materials home? (This may involve consulting with privacy or medical record experts.)

• Are remote staff expected to be logged onto a chat feature or otherwise immediately available?

• What is the expected response time when responding to a critical email, voice-mail, or chat message?

• What is the protocol if expectations are not being met?

(For sample telework agreements, see the resource box.)

IF STAFF MEMBERS NEED NEW EQUIPMENT FOR TELEWORK, WHO WILL BUY IT?

Staff may need a laptop, cell phone, docking station, monitor, or other equipment. Budget and technology support would have to be considered prior to start. It's important to make it clear what your practice will pay for and what employees will have to buy themselves to furnish their home worksites (e.g., office chairs, desks/standing desks, or extra monitors).

IS TELEWORK “AS NEEDED,” SCHEDULED, OR ROTATIONAL?

Practices should consider their telework schedules carefully. They may choose to have a set day during the week for each clinician to do only phone or video visits so the schedule may be predictable, or they may rotate which staff work remotely from day-to-day. In either case, clinics will have to maintain enough on-site staff to cover scheduled in-person visits as well as unscheduled acute care. The remote work schedule may be more flexible for administrative staff, because they are not involved in direct patient care.

Some practices use telework on an ad hoc or “as-needed” basis for inclement weather or other unusual circumstances (e.g., a local outbreak of infectious disease). Those practices must develop a policy for determining who may telework under those circumstances (e.g., staff who don't work with patients in the case of bad weather days, or staff with underlying medical conditions in the case of infectious disease). These policies should include guidance on requesting remote work under those conditions, the criteria under which requests will be approved, and protocols for notifying other staff.

HOW IS TELEWORK MONITORED OR REPORTED?

Practice leadership will need to determine how virtual workloads are monitored and under what circumstances. If a clinician is doing telehealth visits, then the practice can likely pull productivity data from the medical record or billing system. Scheduling or phone queue work by administrative staff may have similar built-in ways to objectively monitor time spent.

For work that is less structured or more subjectively measured, remote employees could simply email their supervisor at the end of the day with a brief list of the work they did that day or complete a provided form. If the workday included meetings or working on documents, the employee may list the nature of what was discussed or completed. This task shouldn't be onerous, just a quick update. If remote employees have historically been high-performing and are keeping up with their workload, additional monitoring may not be required beyond the usual performance management process.

HOW WILL YOUR PRACTICE MAINTAIN COLLABORATION AND TEAMWORK?

When part of the workforce is on site and part is remote, it has the potential to fragment teams. To prevent this, leadership can build in huddles, meetings, and proactive staff engagement (e.g., encouraging camera use during online meetings).

To make sure everyone knows who is teleworking and when, practices may need to have a shared online schedule for all staff, through Microsoft Outlook or another calendar program. Practices also need to have predetermined plans for when a clinician is teleworking and one of their patients presents to the clinic with an acute care issue. One solution is to establish a clinical “buddy system” — whenever one clinician is working remotely, the other must be in the clinic and available to cover.

WHAT IF A TELEWORKING EMPLOYEE NEEDS TO RETURN TO THE OFFICE?

There are a number of reasons why practices might need to bring a remote worker back on site. The reasons could be temporary (e.g., the remote employee needs to cover for a sick on-site employee or the remote employee loses power or internet access at their house) or permanent (e.g., the worker's remote performance is not meeting expectations or the technology proves too difficult). Practices should have policies for how much notice a remote worker is given to return to the office. These parameters should be explained to the employee prior to starting telework and written out in the telework agreement as well.

Prior to terminating the telework arrangement for an underperforming employee, practices may consider having the supervisor conduct more frequent check-ins with the employee to try to get their performance on track.

Have a plan for where remote employees can work when they return to the office, whether temporarily or permanently. This could be a “flex” space if it's a temporary arrangement.

EMBRACING NEW WAYS OF WORKING

The ability to telework can help practices attract new employees, retain existing ones, and provide more flexibility to pivot care delivery in response to emergencies such as the COVID-19 pandemic or other events in the ever-changing medical landscape. By considering the above factors and establishing clear, open, and frequent communication, your practice can successfully implement telework, whether it's just one day per week for all employees, or full-time remote work for some.