Article Figures & Data
Tables
- Table 1.
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
Theme Key Finding Illustrative Quotes Patient, provider, and organization benefits Improved access to care and convenience “Most of the time my diabetes patients will have every three month visits, but telehealth is really good for those patients who actually need more frequent visits as we are adjusting their medication and changing their insulin … and making sure the problems of med adherence are addressed before we get to that three-month mark so that we can actually see improvement sooner rather than waiting until the next in person visits.” (Physician, Clinic A) Increased opportunity for social support “When we do the coaching, some of the children are at home and they hear [recommendations about] controlling your portion, cut down the high carbohydrate food like yams. … So, they help, once we’re done with our appointment they started to notice that you have to stop eating this because the health coach said cut this down. … Having telemedicine really helps in that way.” (CHW, Clinic A) Insights from home environment “It’s hard to measure this, but there’s just something really pleasing about seeing someone in their own environment. So often patients come to our clinic and, you know, they’re on our turf, and it’s a weird place. You know, you get poked, there’s medicines … It’s just, it’s a clinic. … when we call and talk to them on the phone in their home, you’re seeing their kitchen, their living room, the dining room, you see their kids at school or playing in the background. They, you know, they’re more comfortable where they’re at.” (Leader, Clinic A) “The virtual ones with video I’ve gotten the chance to have some insight into the family of my patients and their living situation, which can really give you a much fuller picture of their health and wellness environments.” (Physician, Clinic A) Increased understanding of medication use “I think improved medication understanding, understanding of medication. So being able to say, this, the medication bottle you are holding up right now, is for this condition, and then they can tell you how many times a day they use it. Because sometimes even in person, they might not bring in their medication and they might just refer to them as the little white pill versus like when they’re at home their medications are there, and they can actually show you what they have.” (Physician, Clinic A) Reduced no-show rates “Our clinic no-show rate kind of varies between like 12 and 16% of the time, some days it’s much higher, some days it’s lower, but they started calling patients when they aren’t there on time and asked them if they would like to do a video visit instead. And quite often they’ll say, yes, they didn’t have a ride, or their car broke down or their husband didn’t get off work in time. And so, they still wanted to receive care they just couldn’t get here. And so, that’s been a huge benefit.” (Leader, Clinic A) Challenges of virtual care Reduced information exchange “In person they tend to tell me the story of their life and on the video visit or telephone, yeah, they go right to the point.” (CHW, Clinic A) “If there is an issue with intimate partner violence or even adult elderly abuse, any of those issues you don’t know who the patient is around. And so, when you’re asking these questions you don’t know if the patient is actually giving you the right answer, is there anything else that’s circumstantial that they’re not able to reveal all the information, and so I think there is less understanding of the patient’s circumstances and the environment on the phone.” (Leader, Clinic B) Differing comfort levels “At the very beginning some people were having fun. … But some other people, they were so shy. They were looking somewhere else except the camera.” (CHW, Clinic A) “I think older people a lot of the times what I’ve seen is they want to talk to the provider [in person], see the provider, they seem more connected. Some of them know the staff also well and they kind of connect with the staff as well because they’ve been with the clinic for many years and that makes them less anxious. And they have other issues that they can discuss with the provider, personal issues sometimes that we cannot discuss easily over telehealth or Zoom video visits.” (Physician, Clinic B) Reduced ability to foster interpersonal connection “I know a lot of [patients] express the impersonal experience [with telehealth], so they like to be in-clinic to have someone there that they can talk to and kind of have more of a personal experience.” (Care Coordinator, Clinic B) “I think, you know, there’s always the concern about missing out on your, the interpersonal connection. So, there may be a bit of a difference between patients who are already established and knew their providers and their health coach well versus ones who are maybe newer patients that didn’t have as strong of a connection, but my feeling is that they’re still very much, you know, willing to engage with their care through telehealth.” (Leader, Clinic A) Abbreviation: CHW, Community health worker.
- 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
Pre-Visit Patient Visit Post-Visit Triage Privacy Billing Determining how to optimally triage appointments to be either virtual or in person was an ongoing challenge. The clinics deployed several strategies to increase privacy, which was a key need during virtual appointments. Some patients did not understand that virtual appointments were formal medical appointments that required copays. As such, clinic personnel spent time educating the patients that telemedicine appointments were still subject to billing and copay processes. Intake Virtual Exam Guidance Intake for virtual appointments was conducted by phone instead of in person.
Remote Monitoring
Clinics encountered hurdles in obtaining information such as weight, blood pressure, and vitals remotely. They employed several tactics to address these challenges but reported that strengthening remote monitoring capacity was an ongoing priority.Clinicians received trainings and best practice guidance for how to conduct medical examinations using only the information available virtually.
Distractions
Respondents reported navigating distractions during virtual appointments, including from background noise or patient multitasking. - Table 3.
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
Theme Key Finding Illustrative Quotes Changes in workflow and care processes: Pre-visit Navigating challenges in triaging between in-person versus virtual appointments “I think one of the other challenges has been training with the call center and – we still do not have this done well or done right – but [developing] a matrix or some training for a call center agent to understand when is appropriate for a telehealth visit versus an in-person visit. And that’s been a big challenge for us because there are some services that can be done virtually and others that just absolutely cannot. … Oftentimes there will be issues with a patient on a provider’s schedule with the incorrect visit type. So, it requires everybody to review their schedule well in advance and really monitor, which is not something that used to be a concern.” (Operations Staff, Clinic A) Addressing remote monitoring hurdles “What I do still see as something that is majorly lacking is being able to provide a full set of vital signs. I think for both diabetes as well as for cardiovascular disorders, a proper charting of weights and seeing how that may fluctuate can give some early warning signs of something happening, as well as being able to have accurate monitoring of fasting blood sugar levels. … Remote monitoring would be very helpful.” (Leader, Clinic B) “We do the teaching to make sure that they understand how to use [the devices], but then sometimes when they go home, I will call them back to see how they’re doing … they say, oh, I forgot how to use it. So, having someone else to explain it to another member of the family, so that they know how to use it as well, that has been one of the challenges with some patients.” (CHW, Clinic A) [Regarding blood pressure or glucose monitors] “They’re expensive, so not everybody has them or can afford them, specifically when insurance doesn’t cover it. And they don’t know how to use it sometimes.” (Physician, Clinic B) Changes in workflow and care processes: During a visit Encountering privacy challenges “I’ve had some cases where patients they may agree at the beginning to do a video visit and then when they realize that we are starting to talk about really private issues they tell me that it’s not a good time to talk about it. … So, often times I have patients that step out of the house, go into the backyard so they can talk more freely, but then at the same time that’s also usually when the internet might get worse, so there are some issues that we just can’t address if it’s a concern about privacy.” (Physician, Clinic A) “I’ve had a couple of patients that were clearly dealing with psychiatry issues that wanted to put off on their therapist’s referral just because they had a smaller home with multiple people living in it and they felt uncomfortable talking about their mental health issues with kids around.” (Leader, Clinic B) Obtaining training and best practices for clinicians conducting virtual exams “The more difficult resource investment was trying to get useful best practices and knowledge, sort of have a core group of individuals gathering that information … then sharing it with clinicians. So, this included things like best practices for how to engage patients through the web interaction through telehealth, best practices for what kind of clinical conditions are appropriate versus not appropriate, how to conduct physical exams over camera. And then also kind of learning how to put that information, translate that into electronic health records and also team care when your team was no longer sitting around each other.” (Leader, Clinic A) [Regarding audio-only visits] “Obviously there’s very limited physical evaluation you can do. You know, especially with COVID, … COVID patients aren’t coming in, so we’re starting to be trained and systematic in listening for ‘are they speaking in full sentences, are they coughing, do they sound short of breath, do they sound ill,’ but that’s sort of the extent of what you can tell from audio.” (Physician, Clinic A) Navigating virtual distractions “[Some patients are] doing laundry, cooking dinner, cleaning the house, while they’re sort of having a visit with you. I’d say there’s definitely a distracted group of individuals [on virtual appointments].” (Leader, Clinic A) “We asked them to be in a quiet place when we connect with them. And sometimes that works, [and] sometimes it’s not possible because there are children in the house, but we try to make it as accommodating to whatever they can accommodate in their home.” (CHW, Clinic A) “We don’t go forward with video visits if someone’s in a vehicle. On the phone, someone could very much be in a car driving during the visit, we discourage that, but we can’t hundred percent prevented it. Usually if you’re on video and we see you’re driving, we … tell them we’ll reschedule.” (Leader, Clinic A) Changes in workflow and care processes: Post-visit Educating patients regarding virtual billing protocols “Some, not all of them, but some of them, they thought that when we do the visit by video they thought it’s free, [that] they don’t have to renew their insurance. But then lately we have to educate them to understand that it’s still the same. They still have to renew their insurance.” (CHW, Clinic A) Changes in identifying and addressing social and non-medical needs Changes to screening processes “For adult patients, we’re not doing the same level of social needs assessment. It’s more just people are aware and asking, and I’m asking you know, are you doing okay on rent are you doing okay on food, we have a list of resources.” (Physician, Clinic A) “One of the issues is telemedicine limits the amount you can judge and see. You cannot see the person, or you might be able to but it’s hard to address all issues. It’s different when it’s done in steps when they come to the clinic. They check in, and then they talk to the MA, they talk to the physician, they talk to the person doing checkout. That’s when they used to get the tokens for their ride, so I feel like [with telehealth] the number of people contacting the patient is very limited, and I think the amount the patient can share is also very limited, and so, you’re not seeing their body language if it’s a phone visit, or even if it’s on Zoom I feel like all of that restricts the amount of questions you ask about the social determinants.” (Leader, Clinic B) Lack of a warm handoff/delayed follow up “Before it would be in person, and the doctor would say follow up with this patient navigator, they’ll be able to assist you. After their appointment they’ll come find the patient navigator and it was easier for us to come out and assist them. Versus now, it’s call this patient, we call them, but they don’t pick up the phone.” (Care Coordinator, Clinic B) “In the office we can direct [patients] to the front desk staff or personnel versus with televisit we have to send a task to that person and then that person has to contact the patient so it has added steps, it may not happen in timely matter because of that.” (Physician, Clinic B) Changes in how community resource information and referrals are shared “I have no paper list that I can hand them and circle. … A very small fraction of our patients are signed up for the MyChart portal where I can send them information or links, so it’s harder. … I can tell them a phone number, and they can write it down or I can say I’ll leave it for you at the front desk you can come by or we’ll mail you some stuff but that’s less satisfactory.” (Physician, Clinic A) “Normally we would either hand them a resource, so direct them to like a website or give them the phone number or etc., or a brochure or a pamphlet. Initially it was a little challenging because you had to figure out a way to send them that information digitally or drop it in the mail to them, but we kind of did all of the above.” (Leader, Clinic A) Abbreviations: CHW, Community health worker; MA, Medical assistant.
- Appendix Table 1.
Characteristics of Clinic Personnel Respondents (n = 15) at Two Federally Qualified Health Centers in Northern California
Participant Characteristics N (% or SD) Age in years, mean (SD) 39 (9.4) Percent female 80% Clinic personnel role, N (%) Leader or manager 4 (26%) Primary care physicians 3 (20%) Care coordinator or community health worker 2 (13%) Operations/support staff 6 (40%) Organizational tenure in years, mean (SD) 5.3 (5.1) Responsibilities include patient interaction, N (%) 12 (80%) Racea American Indian 1 (8%) Asian or Pacific Islander 4 (33%) White 3 (25%) Other raceb 1 (8%) Ethnicitya Hispanic/Latino 5 (42%) Non-Hispanic/Latino 7 (58%) Fluent in Spanisha 8 (67%) Abbreviation: SD, Standard deviation.
Note: Rows may not add up to 100% for certain characteristics if respondent(s) did not answer a question. Clinic personnel respondents completed interviews between 2020-2021. Eight respondents participated from Clinic A, and seven from Clinic B.
↵aRace, ethnicity and Spanish fluency were collected only for those whose organizational responsibilities included patient interaction (n = 12).
↵bOther does not include the response options Alaska Native and Black/African American, which were not selected by respondents.
