A Qualitative Study of Primary Care Physicians’ Experiences With Telemedicine During COVID-19
===============================================================================================

* Teresita Gomez
* Yohualli B. Anaya
* Kevin J. Shih
* Derjung M. Tarn

## Abstract

*Background:* Primary care practices rapidly adopted telemedicine visits because of the COVID-19 pandemic, but information on physician perspectives about these visits is lacking.

*Methods:* Fifteen semistructured interviews with practicing primary care physicians and physicians-in-training from a Southern California academic health system and group-model health maintenance organization were conducted to assess physician perspectives regarding the benefits and challenges of telemedicine.

*Results:* Physicians indicated that telemedicine improved patient access to care by providing greater convenience, although some expressed concern that certain groups of vulnerable patients were unable to navigate or did not possess the technology required to participate in telemedicine visits. Physicians noted that telemedicine visits offered more time for patient counseling, opportunities for better medication reconciliations, and the ability to see and evaluate patient home environments and connect with patient families. Challenges existed when visits required a physical examination. Physicians were very concerned about the loss of personal connections and touch, which they believed diminished expected rituals that typically strengthen physician-patient relationships. Physicians also observed that careful consideration to physician workflows may be needed to avoid physician burnout.

*Conclusions:* Physicians reported that telemedicine visits offer new opportunities to improve the quality of patient care but noted changes to their interactions with patients. Many of these changes are positive, but it remains to be seen whether others such as lack of physical examination and loss of physical presence and touch adversely influence provider-patient communication, patient willingness to disclose concerns that may affect their care, and, ultimately, patient health outcomes.

*   Ambulatory Care
*   COVID-19
*   Health Communication
*   Pandemics
*   Primary Care Physicians
*   Primary Health Care
*   Qualitative Research Telemedicine

## Introduction

Opportunities for using telemedicine have existed for some time but have remained limited among primary care providers.1 The coronavirus 2019 (COVID-19) pandemic sparked regulatory changes that reduced barriers to telemedicine and resulted in large-scale expansion of telemedicine use throughout health care systems and primary care practices.2,3 Despite this tremendous growth, insufficient knowledge exists about primary care physician perceptions of telemedicine visits.

Existing studies have focused primarily on patient perspectives about telemedicine visits4⇓–6 or on those of physician specialists and mental health professionals.7,8 Emerging evidence has documented physician views about the challenges of rapidly implementing telemedicine visits in response to the pandemic9,10 and has revealed barriers to patient access such as poor technological competency.11 The few studies that have examined views about physician-patient interactions during telemedicine visits have been primarily from the patient perspective. These studies investigated patient views of interactions with specialists, urgent care, and primary care physicians in Veterans Affairs and academic settings.4,12⇓–14 In-depth exploration of physician perspectives regarding their interactions with patients also is lacking.14 The objective of this study was to identify the range of primary care physician perceptions of the benefits and challenges of telemedicine use, particularly around physician-patient interactions.

## Methods

### Setting, Participants, and Study Design

We invited primary care physicians working in practices affiliated with University of California, Los Angeles (UCLA) Health (an academic medical center), and with a Southern California group-model health maintenance organization, to participate in semistructured interviews. Purposive sampling was used to balance physician characteristics based on gender, age, and training (practicing physician vs physician-in-training). Three participants were identified via snowball sampling, in which participants invited or recommended other potential participants. All physicians had conducted telemedicine visits, although some had newly adopted them within 1–2 months before their interview. The UCLA institutional review board deemed this study exempt from review.

### Data Collection

Physicians participated in 30-minute interviews by video conference between April 19 and June 28, 2020. To provide context, Los Angeles was abiding by a strict stay-at-home order because of the COVID-19 pandemic from March 19 to May 31, 2020. Interviewers used a semistructured interview guide to ask physicians about their views regarding the benefits and challenges of telemedicine visits (interview guide in Appendix). Physicians provided verbal informed consent for the interviews, which were audio recorded and transcribed verbatim for analysis. Physicians were not compensated for their participation.

### Qualitative Analysis

A physician-in-training (TG) moderated all semistructured interviews and was accompanied by DMT (a physician-investigator with qualitative research expertise) for all but 3 interviews. The 2 investigators met after each interview to discuss and assess the interview content for theoretical saturation (when no new themes can be identified from the data),15 which was reached based on consensus. They performed a thematic analysis16⇓–18 in which they reviewed each transcript line-by-line and applied codes to describe obstacles to and facilitators of telemedicine visits. Discrepancies were reconciled via consensus. DMT and KJS (a sociologist) subsequently independently grouped codes into thematic categories. All investigators reviewed the thematic categories, and adjustments were made based on group discussions. EXCEL 2016 was used for data management.

## Results

Fifteen primary care physicians participated in the study, 11 practicing physicians and 4 physicians-in-training. Eight (53%) were women and 6 (40%) were aged 50 years or older. Ten physicians (67%) had no telemedicine experience before the COVID-19 pandemic (Table 1). Below are major themes raised during the interviews that describe a range of physician perspectives regarding the benefits and challenges of telemedicine visits.

View this table:
[Table 1.](http://www.jabfm.org/content/34/Supplement/S61/T1)

Table 1. 
Participant Characteristics

### Telemedicine Improves Patient Access to Care but Leaves Out Some Groups

Physicians highlighted several ways in which telemedicine increases patient access to medical care, including the convenience of not having to “skip work or find a ride to come to the clinic for things you could do over telemedicine” (P6). They stated that telemedicine visits increased patient access by leading to “people seeking care sooner if they needed to; it is more accessible” (P4). Physicians also observed that they felt more comfortable asking patients to follow up more frequently if warranted because with telemedicine visits, patients experience fewer travel-related inconveniences such as traffic and parking. Several physicians noted that patients missed fewer appointments with telemedicine visits because when they call patients who do not show up for a telemedicine visit, “patients will pick up their phone … and it is a way to have adherence to their clinical appointment” (P2). Because patients who are reached by phone can immediately enter a telemedicine visit, physicians perceived that patients were less likely to miss visits, as exemplified by 1 physician’s comment: “I'd say the no-show rate is even less for telehealth [compared with in-person visits] because you can get hold of [patients] easier” (P5).

However, many physicians commented that certain groups of patients have difficulty accessing telemedicine visits. These include patients who do not own or have problems using a smartphone, and as 1 physician explained, “Patients who are less likely to use telehealth are older people who can barely handle their cell phone” (P3). Physicians also observed that older patients often required substantial assistance to participate in a telemedicine visit. As 1 physician observed, “We have to acknowledge that [telemedicine] is not an easy process, especially for people as they get older and they are not computer savvy. Designated staff members in the office might need to spend time ahead of the visit, showing them, this is how you do it” (P10). Another physician noted that “most of my elderly patients, they do not know how to use their phone or the app or they do not really like to deal with technology. Initially, they could give some resistance [to telemedicine], but we encourage families to help them and set up for their video visit and that has worked” (P14).

Another physician observed other obstacles to accessing telemedicine, for example, “if there’s any additional barriers like language or cognition barriers from the patient, it can be really hard to get a good history” (P7) via telemedicine.

### Physicians Believe Many Visits Are Well Suited for Telemedicine

Physicians believed that many types of visits could be conducted successfully via telemedicine, particularly those focused on counseling and discussion that do not require a physical examination. One physician observed, “I suddenly have 6 or 7 or 8 or 9 minutes that I would have spent on physical examination to devote toward discussion” (P3). Visits that physicians deemed well suited for telemedicine included review and discussion of laboratory or other test results, medication initiation for chronic conditions, and as 1 physician stated, “A lot of the mental health issues can certainly be done by telehealth” (P5). Physicians also noted that medication adjustments for chronic conditions such as hypertension and diabetes could easily be done through telemedicine visits if patients have working devices at home to monitor their conditions (ie, blood pressure cuffs, glucometers). One physician observed, “I can even do diabetes follow up [with telemedicine] if I know that the patient has a good blood glucose monitor and is good about keeping data” (P7), particularly because physicians believe it is easier for patients to schedule more frequent follow-up appointments. Another physician remarked, “chronic disease management, I think can be done much more virtually. And I think we’re headed in that direction” (P12). Physicians also commented that: “advance directive talks with the family members [in] this setting is actually really great” (P6) because they could involve family members who otherwise may not have accompanied patients to in-person office visits.

### Seeing Patient Homes and Families during Telemedicine Visits Enhances Patient Care

Physicians noted that a big advantage of telemedicine visits was seeing patients’ home environments. As 1 physician remarked about telemedicine visits: “I get to see what the inside of their house looks like and see where they live” (P7), assess potential safety hazards and home support systems, including pets. Physicians observed that they were able to interact with family members who they otherwise may have never met and, if appropriate, to involve them in the patient’s care. They also commented that medication reconciliations were easier to conduct via telemedicine because “patients can show you their medications, read the labels” (P2), whereas in the office patients often are uncertain about their medication names and regimens.

### Lack of Physical Examination Can Be Problematic for Diagnosis and Treatment of Certain Conditions

Physicians uniformly stated that their inability to perform physical examinations is one of the main disadvantages of telemedicine visits. They noted that some complaints are particularly difficult to assess without a physical examination, such as chest pain, abdominal pain, respiratory complaints, headaches, or gynecological, musculoskeletal, or neurological symptoms. Several physicians voiced that skin rashes were difficult to examine via telemedicine, generally because of physician inability to properly visualize and feel the rash. In addition, several physicians noted that a lack of physical examination could result in antibiotic overprescribing: “I have been a little bit more inclined to treat people with an antibiotic; I have had to err on the side of being more cautious and treating people for things that, otherwise in person, I would not have felt was indicated” (P13).

Worth nothing, however, is that as a result of physician inability to perform physical examinations during telemedicine visits, some physicians observed that these visits may result in better history taking because they have to “become a better detective, diagnostician in terms of asking more relevant questions because you do not have a physical examination; you have more detailed questions and review of systems” (P1) than during in-person office visits.

### Physicians Lament the Lack of “Personal Connections” and Touch during Telemedicine Visits

All physicians spoke at length about the loss of personal connections during telemedicine visits. Whereas some believed that telemedicine and in-person interactions were similar, others noted the challenge of establishing personal connections and rapport via telemedicine, particularly with new patients. Physicians also worried about losing social cues in the virtual space. As one physician noted about the loss of seeing a patient’s body language, “It is hard to replace the in-person [visit], even if you did not need to examine the patient, because you appreciate a lot of the nuances, how the patient's acting in the office, and stuff that you cannot appreciate over telehealth” (P5).

The loss of touch during telemedicine visits bothered physicians, who felt that it detracted from their ability to perform expected rituals of care that form the backbone of physician-patient relationships. Several noted that even though a physical examination is not necessarily required during all visits, both patients and physicians have come to see the examination as being central to physician-patient interactions. As one physician stated, “I think you lose the contact [with telemedicine]. Healing and having people feel like they are being taken care of, a lot [of] that is the physical touching part of it” (P6). Similarly, another commented, “It is an expectation within an interaction with a doctor, to listen to heart, to listen to lungs, it improves patient satisfaction … it is kind of the ritual of the patient-physician relationship” (P2).

Many physicians believed that the loss of personal connection inhibited patients from sharing personal issues during telemedicine visits. As one physician summarized, “You lose that personal connection where I think if someone was in front of you, they would feel a little more comfortable expressing some of their concerns with you” (P13). However, this sentiment was not universal. One physician noted that some patients were more comfortable sharing personal information during telemedicine visits: “I think people seem to be more frank and more likely to make statements than when it is face to face; … it feels a little bit less intimidating to have a separation of video, … particularly for topics considered taboo, like sexual questions” (P10).

### Physicians Feel More Comfortable Refusing Patient Requests during Telemedicine Visits

Several physicians indicated that virtual encounters sometimes made it easier for them to refuse patient requests that they deemed unwarranted. As one physician mentioned, “With telehealth I feel more comfortable telling a patient I am not going to give them their benzodiazepines or their pain medications. They have a video in front of them instead of the person’s right there yelling at me” (P10).

### Telemedicine Visits Tend to Be Shorter than in-Person Visits

Most physicians noted that telemedicine visits tended to be shorter than in-person visits. As one provider pointed out, “I typically limit the small talk on the telehealth a bit more. … I’ve been doing a lot more shorter visits” (P8), whereas another mentioned that “with video visits [patients are] quicker to get off the video. I think patients are wanting to take less time” (P4). On the flip side, a few physicians mentioned that some patients did not realize that telemedicine visits were time limited. One physician observed, “It is kind of easy to lose sight of how much time you have with your provider on the telephone or the video if you are not actively paying attention to it” (P13), although physicians commented that it was easier for them to end telemedicine visits, as opposed to in-person visits.

Physicians mostly voiced satisfaction with these shorter visits, although one physician noted that they may not be conducive for building relationships with patients: “The conversation[s] seemed a little bit shorter. A patient in clinic … there are moments where there’s space for more conversation about not necessarily medical [problems] but just to get to know the patient a little better” (P15).

### Careful Consideration of Physician Workflows Is Needed to Avoid Burnout

Some physicians worried that telemedicine could promote physicians’ provision of on-demand care and lead to potential burnout. “I kind of dread for the future of medicine because what is going to stop us from booking appointments at 9 pm, right? If doctors do not have discipline to control our passion for taking care of people then we might be doing appointments at odd hours; … it could be difficult to maintain work-life balance” (P3).

A major stress-inducing new element in workflow that physicians identified was having to balance schedules that mixed in-person and telemedicine visits because the combination often resulted in physicians running late for visits. As one physician observed, “Schedules are all over the place. And then when someone does not … check in on time, then you get backed up on both ends” (P6). Physicians also expressed that it was difficult for them to switch back and forth from 1 type of visit to another.

### Insurer Reimbursement for Telemedicine Can Reduce Physician Burden

Physicians expressed that a significant benefit of insurer reimbursement for telemedicine visits is that it allows physicians to be reimbursed for evaluations that they normally provide for free. As one physician noted, “The biggest benefit [of telemedicine] is the fact that we primary care doctors already do this; we call people all the time about lab results and handle their problems over the phone. We basically give away highly valuable care for free like that; it is sort of our culture. The culture of medical conversation is changing because of [telemedicine], which is actually going to make these visits more formalized” (P3). Other physicians emphasized the importance of continued reimbursement for primary care telemedicine visits after the COVID-19 pandemic; for example, “I hope that insurances will see the benefit of [telemedicine]; … it just saves money and time for patients and doctors. … I hope that they see that this is where the future of medicine is going” (P6).

## Discussion

Semistructured interviews with primary care physicians revealed that physicians believe telemedicine offers opportunities for improving health care access, is well suited for caring for many medical conditions, and enhances patient care in a variety of ways. With its focus on primary care physician experiences with telemedicine visits, this study adds to existing studies that examined perspectives of patients, physician specialists, and physicians interested in implementing telemedicine.5⇓⇓–8,12,13,19 The positive physician perspectives that arose in this study are consistent with literature showing that patients are satisfied with telemedicine visits and believe they are convenient.5,6,12,14,20 The physician perspectives elucidated in this study add to the literature by informing potential strategies for using telemedicine to augment in-person primary care visits, such as by facilitating accurate medication reconciliations and giving physicians a window into patient home lives—thus bringing new meaning to traditional home visits. Physician insight into patient home environments via virtual home visits can contribute unique information to patient assessments.21 The application of telemedicine to advance care planning can be particularly fruitful because bringing family members into the conversation results in greater patient-surrogate congruence regarding patient preferences.22 Physician perspectives regarding the utility of telemedicine visits for mental health treatment is consistent with the existing literature showing that telemedicine visits are comparable with face-to-face visits with regard to reliability of clinical assessments and clinical outcomes.23⇓–25

However, some physicians also noted various challenges of telemedicine visits. Physicians remarked that telemedicine may improve chronic disease management, but these views are predicated on the assumption that patients are able to access virtual visits. Problems with telemedicine visit access could exacerbate known disparities in care, particularly during pandemics such as COVID-19.26⇓–28 Older patients (especially those 85 years or older), those with low socioeconomic status, and black and Hispanic patients may be particularly affected by this digital divide.29⇓–31 Whereas physicians mostly appreciated having shorter telemedicine visits, other studies have shown that patients may feel rushed during telemedicine visits.8,13 As a result, the brevity of these visits may in fact hinder patient communication. As more patients transition to using telemedicine visits, physicians will need to ensure that patients have adequate opportunities to raise questions and concerns.

The effect of other changes to physician-patient interactions on patient outcomes requires further investigation. Information is needed on how to optimize telemedicine interactions and overcome feelings of loss experienced by both patients and physicians because of the lack of touch during these visits.4,32,33 Good physician-patient interactions are proven to increase patient adherence to treatment recommendations and improve clinical outcomes.34,35 In this study, physicians noted that the lack of physical examination (even when one was not needed for diagnostic purposes) and physical closeness detracted from the patient-physician relationship. Further investigation on this finding is needed, although as a 2019 study of providers of multiple specialties (of which 16% were primary care providers) showed, the majority perceived no difference in personal connection with patients via telemedicine.14 Other studies have shown that patients worry about the lack of physical examinations during telemedicine visits,13 but more information is needed about their perceptions of information disclosure during telemedicine visits. Because some physicians in this study observed greater patient willingness to disclose personal information from the comfort of their own home, our findings suggest that some patients may benefit from having a mix of in-person and telemedicine visits. Table 2 provides suggestions for addressing some of the major challenges of telemedicine visits noted by physicians in this study.

View this table:
[Table 2.](http://www.jabfm.org/content/34/Supplement/S61/T2)

Table 2. 
Major Challenges, Benefits, and Suggested Strategies for Telemedicine Visits

This study has several major limitations. The interviews were conducted toward the onset of the COVID-19 pandemic, and as a result of markedly reduced numbers of primary care office visits, physicians may have been able to conduct patient follow-up visits more frequently than under normal circumstances. The study included physicians from different practices and practice settings, but the majority were affiliated with a single academic health system. We did not collect information on the number of telemedicine visits physicians completed, but all were routinely performing these in their practice. We also did not assess physician training regarding telemedicine visits, video platforms used, or duration of physician relationships with the patients with whom they had conducted telemedicine visits. Although we interviewed a limited number of physicians, we reached theoretical saturation in our analyses. The limited number of total physicians precluded our ability to draw conclusions regarding differences in perceptions among practicing physicians versus physicians-in-training, although no obvious differences were noted. In addition, we did not ask physicians-in-training about the influence of telemedicine on their training because all were within 1–3 months of becoming practicing physicians.

## Conclusions and Implications

Overall, physicians expressed positive views about telemedicine and cited opportunities to leverage telemedicine to improve patient care. They were concerned about patients who were unable to access telemedicine and worried about changes to physician-patient interactions resulting from lack of physical examination and physical closeness. Nonetheless, they were positive about continuing to incorporate telemedicine in their practice. Further studies are needed to quantify the prevalence of these findings and to compare outcomes resulting from telemedicine versus in-person office visits. Future studies are needed to investigate the influence of telemedicine visits, as well as potential changes in physician-patient relationships because of lack of personal closeness, on the quality of patient care, patient adherence to treatments, and patient health outcomes.

## Appendix. Semi-Structured Interview Protocol

1) How would you describe your overall experience with telemedicine?

•What are some positives?

•What are some challenges?

•What types of problems or symptoms are difficult to address with telemedicine?

•What types of problems or symptoms are well-suited for telemedicine?

•How have telemedicine visits differed from your in-person visits?

2) What changes in your practice have you noticed since moving to telemedicine?

3) How do you think patients feel about telemedicine?

•How have your interactions with patients been via telemedicine?

4) What types of disparities (if any) have you noticed in patient care due to the shift to telehealth?

5) What are your thoughts about incorporating telemedicine into your future workflow (after the COVID-19 pandemic)?

## Notes

*   This article was externally peer reviewed.

*   *Conflicts of interest:* Drs Gomez, Anaya, and Shih report no conflicts of interest. Dr Tarn has been funded by the BMS/Pfizer Alliance ARISTA-USA to conduct unrelated research studies.

*   *Funding:* None.

*   To see this article online, please go to: [http://jabfm.org/content/34/Supplement/S61.full](http://jabfm.org/content/34/Supplement/S61.full).

*   Received for publication October 1, 2020.
*   Revision received November 12, 2020.
*   Accepted for publication November 12, 2020.

## References

1.  1.Kane CK, Gillis K. The use of telemedicine by physicians: still the exception rather than the rule. Health Aff (Millwood) 2018;37:1923–30.
    
    

2.  2.Keesara S, Jonas A, Schulman K. Covid-19 and health care’s digital revolution. N Engl J Med 2020;382:e82.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJMp2005835&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

3.  3.Shachar C, Engel J, Elwyn G. Implications for telehealth in a postpandemic future: regulatory and privacy issues. JAMA 2020;323:2375–6.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/jama.2020.7943&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=32421170&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

4.  4.Powell RE, Henstenburg JM, Cooper G, Hollander JE, Rising KL. Patient perceptions of telehealth primary care video visits. Ann Fam Med 2017;15:225–9.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMy8yMjUiO3M6NDoiYXRvbSI7czoyOToiL2phYmZwLzM0L1N1cHBsZW1lbnQvUzYxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  5.Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ open 2017;7:e016242.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiYm1qb3BlbiI7czo1OiJyZXNpZCI7czoxMToiNy84L2UwMTYyNDIiO3M6NDoiYXRvbSI7czoyOToiL2phYmZwLzM0L1N1cHBsZW1lbnQvUzYxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  6.Polinski JM, Barker T, Gagliano N, Sussman A, Brennan TA, Shrank WH. Patients' satisfaction with and preference for telehealth visits. J Gen Intern Med 2016;31:269–75.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1007/s11606-015-3489-x&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

7.  7.Brooks E, Turvey C, Augusterfer EF. Provider barriers to telemental health: obstacles overcome, obstacles remaining. Telemed J E Health 2013;19:433–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1089/tmj.2013.0068&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=23590176&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

8.  8.Mammen JR, Elson MJ, Java JJ, et al. Patient and physician perceptions of virtual visits for Parkinson’s disease: a qualitative study. Telemed J E Health 2018;24:255–67.
    
    

9.  9.Barney A, Buckelew S, Mesheriakova V, Raymond-Flesch M. The COVID-19 pandemic and rapid implementation of adolescent and young adult telemedicine: challenges and opportunities for innovation. J Adolesc Health 2020;67:164–71.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/j.jadohealth.2020.05.006&link_type=DOI) 

10. 10.Srinivasan M, Asch S, Vilendrer S, et al. Qualitative assessment of rapid system transformation to primary care video visits at an academic medical center. Ann Intern Med 2020;173:527–35.
    
    

11. 11.Latus-Olaifa O, Norman GJ, Kurliand M, et al. Not yet ready for prime time: video visits in a home-based primary care program. J Am Geriatr Soc 2019;67:2202–4.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

12. 12.Elliott T, Tong I, Sheridan A, Lown BA. Beyond convenience: patients’ perceptions of physician interactional skills and compassion via telemedicine. Mayo Clin Proc Innov Qual Outcomes 2020;4:305–14.
    
    

13. 13.Gordon HS, Solanki P, Bokhour BG, Gopal RK. “I’m not feeling like I’m part of the conversation”: patients' perspectives on communicating in clinical video telehealth visits. J Gen Intern Med 2020;35:1751–8.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

14. 14.Donelan K, Barreto EA, Sossong S, et al. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care 2019;25:40–4.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

15. 15.Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006;18:59–82.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1177/1525822X05279903&link_type=DOI) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000242853100004&link_type=ISI) 

16. 16.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1191/1478088706qp063oa&link_type=DOI) 

17. 17.Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods 2017;16:160940691773384.
    
    

18. 18.1.  Liamputtong P
    
    Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P, ed. Handbook of research methods in health social sciences. Singapore: Springer Singapore; 2019:843–60.
    
    

19. 19.Samples LS, Martinez J, Beru YN, Rochester MR, Geyer JR. Provider perceptions of telemedicine video visits to home in a veteran population. Telemed e-Health 2020;:null.
    
    

20. 20.Reed ME, Huang J, Parikh R, et al. Patient-provider video telemedicine integrated with clinical care: patient experiences. Ann Intern Med 2019;171:222–4.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

21. 21.Ramsdell JW, Swart JA, Jackson JE, Renvall M. The yield of a home visit in the assessment of geriatric patients. J Am Geriatr Soc 1989;37:17–24.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1111/j.1532-5415.1989.tb01563.x&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=2909601&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1989U452100003&link_type=ISI) 

22. 22.Song M-K, Kirchhoff KT, Douglas J, Ward S, Hammes BA. Randomized,. controlled trial to improve advance care planning among patients undergoing cardiac surgery. Med Care 2005;43:1049–53.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1097/01.mlr.0000178192.10283.b4&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=16166875&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000232194700013&link_type=ISI) 

23. 23.Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental health: a 2013 review. Telemed J E Health 2013;19:444–54.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1089/tmj.2013.0075&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=23697504&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 

24. 24.Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World J Psychiatry 2016;6:269–82.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.5498/wjp.v6.i2.269&link_type=DOI) 

25. 25.O'Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr Serv 2007;58:836–43.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1176/appi.ps.58.6.836&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=17535945&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000253360100015&link_type=ISI) 

26. 26.Anaya YB, Martinez LE, Vargas-Bustamante A, et al. Telehealth and COVID-19: policy considerations to improve access to care. Center for the Study of Latino Health and Culture (CESLAC), David Geffen School of Medicine and UCLA Latino Policy and Politics Initiative, Luskin School of Public Affairs. 2020. Available at: [https://latino.ucla.edu/research/telehealth-covid-19-policy-considerations-to-improve-access-to-care/](https://latino.ucla.edu/research/telehealth-covid-19-policy-considerations-to-improve-access-to-care/).
    
    

27. 27.Martinez LE, Vargas-Bustamante A, Anaya YB, et al. COVID-19 in vulnerable communities: an examination by race/ethnicity in Los Angeles and New York City. Center for the Study of Latino Health and Culture (CESLAC), David Geffen School of Medicine and UCLA Latino Policy and Politics Initiative, Luskin School of Public Affairs. 2020. Available at: [https://latino.ucla.edu/wp-content/uploads/2020/07/LPPI-LA-v-NY-Report.pdf](https://latino.ucla.edu/wp-content/uploads/2020/07/LPPI-LA-v-NY-Report.pdf).
    
    

28. 28.Khatana SAM, Groeneveld PW. Health disparities and the coronavirus disease 2019 (COVID-19) pandemic in the USA. J Gen Intern Med 2020;35:2431–2.
    
    

29. 29.Lam K, Lu AD, Shi Y, Covinsky KE. Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. JAMA Intern Med 2020;180:1389.
    
    

30. 30.Roberts ET, Mehrotra A. Assessment of disparities in digital access among Medicare beneficiaries and implications for telemedicine. JAMA Intern Med 2020;180:1386.
    
    

31. 31.Reed ME, Huang J, Graetz I, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Netw Open 2020;3:e205873.
    
    

32. 32.Clancy CM, Kirsh S. Virtual care and the pandemic: are we reaching all patients? Ann Intern Med 2020;174:116–117.
    
    

33. 33.Hyman P. The disappearance of the primary care physical examination—losing touch. JAMA Intern Med 2020;180:1417.
    
    

34. 34.Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med 1995;40:903–18.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/0277-9536(94)00155-M&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=7792630&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1995QN62400005&link_type=ISI) 

35. 35.Zill JM, Christalle E, Müller E, Härter M, Dirmaier J, Scholl I. Measurement of physician-patient communication—a systematic review. PloS One 2014;9:e112637.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1371/journal.pone.0112637&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=25532118&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS61.atom)