Abstract
Background: Federally qualified health centers (FQHCs) rapidly adopted and implemented telemedicine during the COVID-19 pandemic. This study analyzes FQHC personnel accounts of care redesign strategies to support telemedicine implementation in 2020 and 2021, and identifies improvement opportunities.
Methods: We conducted semistructured, in-depth interviews with clinic personnel (n = 15) at 2 FQHCs in Northern California (December 2020-April 2021) to examine telemedicine adoption and use of audio-video and audio-only/phone telemedicine encounters.
Results: FQHC clinicians and staff reported that telemedicine implementation increased access to care and reduced appointment no-show rates. However, a reported reduced ability to develop and foster interpersonal connections negatively impacted clinician-patient relationships. Care redesign strategies included systems to triage appointment types (in-person versus virtual), work-arounds to screen for and address social and nonmedical needs, and new protocols to navigate privacy needs for first time telemedicine users. In addition, increasing remote monitoring capabilities was deemed an important priority for improving telemedicine use for marginalized populations.
Conclusions: Telemedicine implementation in FQHCs involved care redesign to optimize virtual interactions and care processes. Guidelines and evidence-based practices are needed to improve telemedicine use in FQHCs, including strategies to support interpersonal connections; approaches to virtually screen for and address social needs; and protocols to further mitigate privacy issues. Future research is needed to identify when telemedicine can optimally supplement in-person care to improve patient outcomes and clinic efficiency, particularly in safety net settings.
- Community Health Centers
- COVID-19
- Health Services Accessibility
- Implementation Science
- Pandemics
- Primary Health Care
- Qualitative Research
- Quality Improvement
- Safety-Net Clinics
- Telehealth
Introduction
Before the COVID-19 pandemic, telemedicine adoption was limited in federally qualified health centers (FQHCs),1 which serve socioeconomically vulnerable populations. In 2019, only 43% of FQHCs reported providing telemedicine visits compared with 99% in 2020.2,3 For FQHCs that used telemedicine prepandemic, 75% offered telemental health services whereas only 28% used telemedicine for primary care.2 The pandemic accelerated telemedicine implementation.4,5 By 2020, 97% of FQHCs reported using telemedicine to deliver primary care.3
Telehealth studies conducted during the pandemic document benefits, including increases in access to care, and challenges, such as clinician difficulty establishing interpersonal connections and conducting physical exams virtually.6⇓⇓–9 Most pandemic-era telemedicine research has focused on implementation in outpatient or primary care settings broadly,6⇓⇓⇓–10 or for specific populations (e.g., the elderly, adolescents).11⇓–13 Few have examined telemedicine implementation experiences in FQHCs.14,15
The aim of this study is to characterize the care redesign undertaken by 2 FQHCs as they implemented telemedicine during the pandemic. We examine benefits and challenges experienced, as well as work-arounds deployed to overcome hurdles.
Methods
We conducted semistructured interviews with FQHC personnel to collect information about changes to care provision during the COVID-19 pandemic. The study involved 2 California FQHCs that predominantly serve immigrant communities (Chinese, Latino). By April 2020, both offered telemedicine visits for the first time. Eligible clinic personnel were involved in telemedicine adoption decisions or had direct implementation experience, and were recommended by a clinic liaison for participation.
The interview guide included questions about COVID-19 video and audio-only telemedicine experiences, impacts to clinic operations, perceived sustainability, and recommendations. The questions and qualitative codebook were developed based on telemedicine research,12,16⇓⇓⇓⇓⇓⇓–23 and the Technology Acceptance Model,24 which highlights perceived ease of use and perceived usefulness of technologies as key determinants. The instruments were also developed based on organizational capacity frameworks25,26 and theories of implementation climate,27 which highlight that innovations need to align with users’ values and organizational capabilities.
Eligible and interested respondents provided verbal consent before participating in a remote interview (December 2020–April 2021), which was audio-recorded with permission. Participants received a $25 gift card. Recruitment ceased when data saturation was attained for key themes. Additional details are described elsewhere.28 The Institutional Review Board of the University of California, Merced, approved study protocols and materials (UCM2020-85).
Eight themes (implementation facilitators; challenges; modality-specific experiences; perceived benefits; patient-physician relationship changes; changes affecting workflow, care processes, and quality; patient misconceptions; and social and nonmedical needs) and 33 related codes (of 107 total codes) were analyzed. A coauthor independently coded transcripts to streamline data analysis,29 with guidance from the lead author. The team held weekly meetings to discuss discrepancies and obtain consensus.
Results
Fifteen clinic personnel from 2 FQHCs completed interviews (duration: 48 to 85 minutes), including clinic leadership, physicians, community health workers (CHWs), and operations/support staff. See personnel characteristics in Appendix Table 1. Illustrative quotes for findings are in Tables 1 and 3.
Telemedicine Implementation: Perceived Benefits and Challenges During the COVID-19 Pandemic, Personnel (n = 15) from Two Federally Qualified Health Centers in Northern California, 2020–2021
Telemedicine Benefits, Challenges
Physicians indicated improved quality of discussion about medications in virtual appointments, particularly for chronically ill and elderly patients. Medications were generally accessible at home and patients could easily verify information or show their medication on screen. Physicians also noted seeing patients at home provided a “fuller picture of health and wellness environments.”
Interpersonal connections were noted to be harder to establish via telemedicine. Respondents said the amount of information patients shared via telemedicine was less than inperson. Some patients were described as feeling rushed or less likely to share sensitive experiences (e.g., intimate partner violence, elderly abuse). Respondents said some patients appeared less confident or comfortable in virtual visits, which could impact their engagement. However, clinicians noted video visits at least afforded them the ability to see patients “face-to-face,” which facilitated patient-physician relationships.
Despite limitations, personnel reported telemedicine improved access to care. Telemedicine decreased appointment wait times and increased touch points with clinic personnel. Virtual appointments and health education classes were also viewed as more accessible to patients’ family members/caregivers, who could provide social support to facilitate care and/or health management, including dietary and lifestyle changes. Other benefits included reduced no-show rates, which may have led to efficiency gains by decreasing service delivery disturbances. Personnel attributed no-show reductions to the relative convenience of telemedicine, as patients could attend appointments from work/home. This was especially important for their patient population, for whom missing work or finding transportation and/or childcare could be difficult.
Changes in Workflow and Care Processes
Respondents shared changes in workflow and care processes resulting from telemedicine use [Table 2].
Changes Affecting Care Provision and Clinic Operations at Multiple Workflow Time Points in Two Federally Qualified Health Centers During the COVID-19 Pandemic, 2020–2021
Telemedicine Implementation: Changes to Care Provision and Processes During the COVID-19 Pandemic, Described by Personnel (n = 15) in Two Federally Qualified Health Centers in Northern California, 2020–2021
Characteristics of Clinic Personnel Respondents (n = 15) at Two Federally Qualified Health Centers in Northern California
Part of the operational impact of telemedicine adoption was navigating triaging patients to in-person or virtual appointments, including whether a virtual appointment required video, or whether phone (audio only) was sufficient. Even with training and protocols in place, triaging was an ongoing challenge with a steep learning curve to determine the appropriate visit type.
Virtual appointment intake was conducted by phone. Medical assistants said gathering weight and blood pressure information was contingent on the availability of remote monitoring resources. Because patients were often not able to afford blood pressure monitors, clinics distributed a limited number of the devices, funded by grants or donations. Additional challenges remained, including patient knowledge gaps in operating devices, physical limitations using devices, and inconsistencies of readings. Clinics responded by training patients, asking patients to bring devices in to assess accuracy, or relying on in-person vitals. Even with these strategies, weight and blood pressure measures were commonly not available or recorded. Improving remote monitoring was considered a high priority for telemedicine sustainability.
Physicians received training for how to conduct exams virtually, including maximizing available contextual cues, such as listening for shortness of breath.
As the clinics serve a safety-net population, many of their patients live in crowded home environments, which personnel were concerned negatively impacted privacy and caused patients to delay behavioral health care. To address privacy needs, clinic personnel routinely asked patients if they were in a private space, created passcodes on virtual applications, switched to phone visits when necessary, and had interpreters join by phone.
Distractions were said to increase for some patients while using telemedicine (e.g., from background noise and multitasking, including household chores), which could reduce patients’ attention and engagement. To decrease distractions, patients were asked to join from a quiet location. If patients were driving, clinics rescheduled appointments.
Patient misconceptions/confusion about telemedicine billing was common. As a result, clinic staff spent time educating patients that virtual sessions were formal medical appointments with copays/fees.
Changes in Addressing Social Needs
Although clinics integrated social needs screening questions into telemedicine visits, the assessments were said to be generally less in-depth compared to in person assessments. When social needs were identified, physicians were not able to provide a warm handoff to patient navigators. To address this, 1 clinic added a protocol to assign tasks to navigators to follow up with patients afterward. This, however, could take several attempts, resulting in delays.
Clinics also developed work-arounds to provide social needs referrals and community resource information, using e-mail, text, mail, phone, and/or patient portals; posting information to web sites/social media; and leaving printed materials for pick-up at the clinic. Several of these were considered suboptimal compared with distribution during in-person appointments.
Discussion
We investigate care redesign that transpired in 2 FQHCs as they adopted and implemented telemedicine during the COVID-19 pandemic to meet the needs of a marginalized patient population, who have historically faced barriers in accessing virtual care.30⇓–32
Our study found several benefits, including telemedicine’s potential to improve the quality of medication discussions. To optimize this benefit, patients should be advised to have medications readily accessible during telemedicine visits. Another recommendation based on our findings is increasing family engagement – a noted benefit in adult and pediatric care settings,6,33⇓–35 as they can help gather vitals35 or manage care.33 Our findings reveal there are also benefits to including family members in virtual health education sessions, as they can support lifestyle changes. Future research should explore best practices for this inclusion.
Continuing and strengthening remote monitoring capabilities was seen as necessary to sustain high quality telemedicine for FQHC patients, who often are not able to afford devices on their own. Because lack of reimbursement is a noted issue,36 expanding device reimbursement and increasing staff time to monitor/educate patients could support improved remote monitoring integration.
We also found that FQHCs retooled workflows and care processes for telemedicine use. A key challenge was determining appropriate appointment triage paths, noted in related studies.8,11 Although our FQHCs and others37,38 have developed their own triage protocols, creating standard guidance for clinics to make efficient and clinically appropriate triage decisions would be beneficial.
Guidelines are also needed to improve virtual privacy standards for FQHC patients. Existing recommendations include modifying clinic environments and employing strategies to increase patients’ ability to manage information shared.12,35,39⇓⇓⇓⇓–44 Clinics’ strategy of using phone visits to increase privacy underscores the need to continue offering audio-only visits in FQHCs, whose patients often have few alternative privacy-enhancing options.
Telemedicine implementation led to modifications to screening for and addressing social needs. Evidence-based virtual screening protocols are needed, including determining optimal modes for specific populations (e.g., synchronous virtual screening versus online tools).45 Investment is also needed to integrate “warm handoffs” to patient navigators into telemedicine platforms and improve virtual distribution of social need referrals/resources.
Limitations include a modest sample size and long fielding period, which reflect pandemic-related recruitment challenges. Despite this, perspectives from clinicians and staff offer a nuanced understanding of care redesign early in the pandemic in FQHCs. As the interviews took place at only 2 FQHCs, generalizability is limited. However, given the consistency of experiences reported across clinics with distinct immigrant populations, the findings are likely relevant to FQHCs that serve similar marginalized or immigrant populations.
Conclusions
Our qualitative study of FQHC telemedicine implementation highlights workflow modifications and work-arounds for multiple care processes during the pandemic. To improve telemedicine implementation in FQHCs, resources and evidence-based practices are needed to support interpersonal connections, guide triage decisions, mitigate privacy issues, increase remote monitoring capacity, and improve ways to identify/address social needs virtually.
Acknowledgments
Authors thank Elena Alcala, Kayla Williams, and Danielle Malone of the Community Health Partnership for their assistance in recruiting clinicians and staff to participate in the study. Authors also would like to thank the clinician and staff participants for their time and participation.
Notes
This article was externally peer reviewed.
This is the Ahead of Print version of the article.
Funding: This study was supported by grants from the Center for Information Technology Research in the Interest of Society (CITRIS), Banatao Institute at the University of California (2020-0000000001) and the Health Trust of Santa Clara County. Dr. Frehn was supported by postdoctoral training grant T32HS000046 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not represent the official views of CITRIS, the Banatao Institute, or AHRQ.
Conflict of interest: Authors have no conflicting or competing interests to report.
To see this article online, please go to: http://jabfm.org/content/00/00/000.full.
- Received for publication October 28, 2022.
- Revision received December 7, 2022.
- Revision received April 10, 2023.
- Accepted for publication April 24, 2023.
