Article Figures & Data
Tables
- Table 1.
Key Concepts About Appropriateness and Motivators Expressed by Clinicians and Patients
Key Concept Category Concepts from Clinicians Concepts from Other Key Informants Potentially Appropriate for Telemedicine Care coordination Care coordination Chronic condition management Chronic condition management Diabetes COVID-19 testing decision making Diagnosis is known already Medication reconciliation Education Mental health counseling Get acquainted with new doctor Minor things Goals of care are clear Post discharge Medication reconciliation Preoperative low risk procedure Mental health counseling Preventative medicine/cancer screening Minor things Refills Musculoskeletal Returning results Neurological Symptoms can be described completely Non-emergent To replace an Urgent Care visit Other sources of information With “extenders” in community Post discharge Preoperative low risk procedure Preventative medicine/cancer screening Pt education Rash Refills Sensitive issue Substance use disorder Symptoms can be described completely When home measures available and valid With “extenders” in community Potentially Inappropriate for Telemedicine Abdominal pain Check-up/physical Bad news Driven by desire to bill Check-up/physical Need for exam Diagnostic dilemma New condition/detect a change Genital examination Preoperative Lymphadenopathy Severe issue Musculoskeletal Substance use disorder Need for a procedure Need for exam Need for specimens collected by clinician Need for vaccination New clinician New condition/detect a change New patient New symptom in complex patient Pregnancy care Preoperative Risk of unsuccessful transition of care Sensitive issue Severe issue Substance use disorder Unintended weight loss Motivating Towards Telemedicine Ability to share screen Allows avoidance of travel/parking Allows avoidance of travel/parking Allows rapid access Allows environmental assessment Avoid infectious exposures Allows rapid access Avoid copay of office visit Avoid infectious exposures COVID-19 Caregiver present Gets care/visit more quickly Clinician is paid for time Good if mobility challenges COVID-19 Helps avoid higher level of care Doctor is focused on patient New model of care Doctor stays on schedule Patient has comfort with technology Efficiency (time saving for patient Patient is care giver for homebound Family support Transportation issues Gets care/visit more quickly Value based copay adjustments Good if mobility challenges Well established relationship Helps avoid higher level of care Improves visit adherence Information sharing Managing uncertainty/anxiety Medications readily available for review Patient has access to technology Patient has comfort with technology patient isolation/access to social network Reducing low value services Transportation issues Well established relationship Motivating Away from Telemedicine Absence of needed information for decisions Absence of needed information for decisions Adds visits that might not usually happen Adds visits that might not usually happen Distracted patient Doctor-patient relationship/trust Doctor-patient relationship/trust Inequities driven by copay differences Harder to ask questions New work flows not in place Inability of patient to retain information Taking personal amity out of relationships Missed diagnoses Technology limitations New work flows not in place Unintended harm on subpopulations Office visit is a social event for patient Privacy Taking personal amity out of relations Technology limitations Unnecessary antibiotics Other Contextual Factors Expressed as Influencing Decision-Making Clinician comfort/preference Algorithmic triage Doctor selects visit type Clinician comfort/preference Nurse triage process Doctor selects visit type Patient preference Driven by reimbursement and/or co-pays Reimbursement considerations Patient preference Telemedicine as default Patient selects visit type Recommendation from professional society Reimbursement considerations Standards of care Potentially Appropriate for Telemedicine Chronic condition management
“I just did three telehealth visits this morning for things that are psychiatric/psychologic, those worked very well.” (C7)
“…diabetes care is one of those where I think it works very well. Depression and mental health is one where I think it actually works very well.” (C4)
“… a visit with the home health nurse and the patient together and me…. With me on the phone or with the nurse turning a video on would be fabulous use [of telemedicine post-discharge.]” (C3)
Information gathering
“So, for example, like a post hospitalization visit, you think would be something you would really want an exam … but actually the work is, the large majority of the time, just making sure the home health services are in place.”(C5)
“…following up on measurements they made at home, like blood sugar or blood pressure.” (C3)
“So if you don't need to do anything invasive …where you don't need a specimen from the patient, where you don't need to be in the same room for the patient, I think it works very, very well.” (C7)
Symptoms can be described
“And I mean, even vomiting, I don't want to leave the house. And I think it's easy enough to explain your symptoms to a doctor…”(P4)
“Yeah. I was able to verbally explain …what the symptom was, and that was fine” (P5)Potentially Inappropriate for Telemedicine Physical examination or a procedure needed
“…my yearly checkup. So I don't think that that could have been done online either.” (P2)
“I'm overdue for my shingles and pneumonia shots.” (P1)
“And sometimes there are things that I need to see in person, like a wound, … people are generally willing to come….” (C1)
Diagnostic uncertainty
“But if it's something that maybe has been re-occurring and is much more nerve-racking, I think that you would want to be in person.” (P7)
“If there is a reason we are visiting doctor to figure something out, I feel it's better we go and meet.” (P3)
“…antibiotics could have been withheld if the diagnosis was made in person, with all of the information gathered during a face-to-face visit.” (C1)
Possibly severe situation
“ …if it was something to do with breathing and lungs, I don't know that I would feel comfortable with [telemedicine.]” (P5)
“… because of my recent history, I would have felt much more comfortable in person.” (P2)Motivating Towards Telemedicine Overcoming barriers
“What is [the reason for] the tremendous increase in the show rate? … part of that is probably transportation; part of it is probably child care.” (C4)
“So convenience, eliminate transportation.” (O1)
“I'm in a wheelchair, I need someone to go with me.” (P4)
Time efficiency
“It really pushed doctors to keep to a time schedule … they would really disrupt their full schedule if they allowed themselves to fall behind.” (P2)
“…the patients have a different sense of time on the video visit or the telephone visit, like they often want it to be short because it's…their time, not your time.” (C5)Motivating Away from Telemedicine Privacy concerns
“If I can't assess … if I truly don't trust that they're in a safe space.” (C5)
“…for myself, personally, I would be completely turned off by [meeting a new clinician] … I think that I would be worried that it could be anybody, literally anybody.” (P2)
Technology challenges
“And then we lose the sound and then we lose the video; and then it gets disconnected and then it gets reconnected or we can't start. Or halfway through I finally abandon video because it's pixilated and … just call them on the phone.” (C3)
“…so I'm sure that it's of almost no value to the patient because they're not going to remember anything [without an after visit summary on paper]” (C3)
Potential harms to health system
“…a provider who really needs volume can certainly crank out quite a few phone calls in an hour and expect payment for them..” (O2)Other Contextual Factors Expressed as Influencing Decision-Making Decision-making about type of visit
“…my presumption is that… if telemedicine was offered that my doctors felt comfortable that [this] would be the way for us to carry out my next appointment.” (P7)
“Maybe we can make telemedicine as the default if the patient doesn't ask. And then I think the onus should be on the physician to make sure [it is appropriate.]” (P3)
“[Some patients] don't want to do a video visit…sometimes it is because they don't have the capability to do it, they don't feel confident they can do that, or they just really feel strongly that they need a face-to-face visit.” (O3)
“I worry a little bit that patients who may or may not have financial means, choose delivery options that save them money and may not be really at the level that they need.” (O2)Note. Alphabetized within theme and column.
