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.