Forty-two physicians participated in the study: 20 family physicians in Quebec and 22 PHC physicians in Massachusetts, who provided care to patients in general internal medicine, pediatric, and family medicine practices. We identified four key themes related to conducting telehealth in PHC, as perceived by physicians in the two contexts: 1) access for patients; 2) efficiency of care delivery; 3) professional impacts; and 4) relational dimensions of care. For each theme, we report the positive and negative implications from those physicians’ perspectives (see Table 1).
I. Positive and negative implications related to patients’ access to health services
The first theme centered on the fact that accessing healthcare services via telehealth is easier and more convenient for some patients than to face-to-face appointments. Patients do not need to travel to and from their appointments, take as much (or any) time off work, or spend time in waiting rooms. Not needing totravel was perceived as an advantage, in that this saves time as well as transit and parking costs. This was considered particularly beneficial for patients who experience physical or financial barriers to access, including the elderly, those with mobility impairments, those living in rural areas, and those with low incomes. Scheduling appointments was also perceived to be more convenient. According to respondents from both sites, patients appreciated not having to leave work for appointments or arrange for childcare. Our analyses suggest that physicians favor maintaining telehealth services following the pandemic, given that patients do not need to rearrange their schedules to the same extent as for face-to-face visits.
On the other hand, some patients face technological barriers that hinder their use of telehealth and thus their access to health services. For instance, video consultations presented difficulties for some patients, such that reverting to telephone (audio only) appointments was sometimes necessary. Respondents mostly perceived this as being due to patients’ lacking the necessary tools (e.g., email, smartphone), or the skills to adequately use these tools, as well as to characteristics such as hearing impairment or vulnerability (e.g., low income). Some Quebec respondents explained that they did not encourage their elderly patients to try the video telehealth experience. They considered that installing video capability could be complicated, time-consuming, and require technical support— difficult to obtain in a pandemic context—and thus did not focus on this care delivery modality for these patients. Table 2 presents quotes to support each sub-theme identified.
II. Positive and negative implications related to efficiency of care delivery
The second key theme had to do with participants’ perceptions of how telehealth use transformed care delivery. Positive implications reported by respondents in Quebec and Massachusetts included increased efficiency for follow-up care, the ability to see patients more frequently when needed, improved rapidity of care delivery (shorter wait times for appointments, shorter duration of consultation), and fewer missed appointments. With respect to the diagnostic process, however, respondents had opposing perceptions about the effectiveness of remote consultations. On one hand, they now questioned the need for face-to-face appointments for situations in which the patient’s history was sufficient to make a diagnosis (i.e., no physical examination needed). On the other hand, they pointed out the difficulty of diagnosing without a physical exam and visual information. Table 3 presents key quotes from both care contexts.
Participants considered telehealth to be excellent for follow-up appointments that did not require examinations, such as brief appointments focused on treatment compliance, the benefits or side effects of a new medication, or follow-up about mental health concerns. Also, telehealth reportedly made it possible for providers to connect more frequently with their patients, as needed.
Several physicians in both sites reported that telehealth appointments were sometimes less time-consuming than face-to-face visits. With respect to completing clerical work, telehealth appeared to have had a positive effect in Quebec, but both positive and negative effects were reported in Massachusetts. Some respondents reported they were better able to complete their notes when using telehealth, while others said they had trouble navigating video consultations and EMRs, resulting in their falling behind with notes and follow-up actions needed after the telehealth appointments. Another aspect of telehealth that contributed to perceptions of greater efficiency was the ability to communicate with patients via email to exchange documents, such as photographs. In Quebec, some physicians reported that the pandemic had accelerated their use of emails with patients, which they had not used before. Our results also suggest that telehealth may have increased efficiency by decreasing the number of missedappointments. This may have been because consulting remotely allowed more flexibility with appointment times and greater convenience for patients.
In terms of negative aspects related to efficiency of care delivery, physicians from both Quebec and Massachusetts reported that, for some pathologies, it is harder to establish a diagnosis without a physical exam and non-verbal information, making remote examination difficult. For example, some acute mental health and pain cases reportedly require face-to-face appointments, as do new musculoskeletal cases and pregnancy.
Respondents also raised concerns about potential medical errors, as telehealth made it more difficult to properly diagnose patients. For appointments conducted over the phone, our results suggest that the lack of visual information hindered physicians’ ability to evaluate patients’ understanding of their condition (literacy, language barrier, difficulty in asking/responding to questions, etc.), thus posing diagnostic difficulties.
In Quebec, duplication of visits was mentioned as an important challenge. When remote consultation was not sufficient to assess patients’ conditions, sometimes patients had to come in for face-to-face visits. Our analyses revealed the importance of being able to assess beforehand the appropriateness of a telehealth consultation, as opposed to a face-to-face visit, when booking appointments. As nurses were redeployed from PHC to hospital settings during the COVID-19 pandemic, triage fell to administrative assistants, who lacked the necessary clinical training, and ultimately some physicians became involved in this role. In Massachusetts, this “duplications” of roles was perceived as a viable triage mechanism. Respondents from both sites reported that, in some practices, a telehealth appointment was required before a patient could be scheduled for a face-to-face consultation.
III. Positive and negative implications related to professional impacts
This theme refers to how telehealth transformed the way providers work and to its impacts on physicians’ practices. The positive aspects in both contexts related to how teleworking had increased providers’ scheduling flexibility and availability for patients via telehealth appointments. The negative aspects related to decreased opportunities for team building and technological limitations. Table 4 shows keys quotes related to positive and negative professional impacts in both contexts.
Physicians perceived that the ability to work from home improved their quality of life. Given the pandemic context, teleworking allowed those with a greater risk of contracting the virus (e.g., older physicians) to continue working, and several respondents emphasized their hope that teleworking remain possible in certain situations following the pandemic.
Telehealth also provided physicians greater schedulingflexibility and availability for patients. They could choose when they would be available for telehealth appointments. However, while physicians were less concerned about inconveniencing patients when they were delayed, given that those patients were not waiting in physical waiting rooms, their inability to notify patients about such delays was mentioned as a concern.
Prior to the pandemic, while some physicians provided telehealth services, the lack of compensation for these was a barrier to their use. Our respondents reported appreciating that telehealth is now formally recognized and reimbursed as a care provision modality.
The negative aspects reported by both Quebec and Massachusetts respondents related to team building (less sharing of competencies, reduced social contact) and technological limitations for providers and their practices. Because physicians are trained primarily to deliver care in person, our respondents considered the absence of telehealth training problematic, particularly with respect to using virtual tools to make diagnoses as well as the complexity of learning new software under pressure at the outset of the pandemic. Physicians also reported struggling with how to nurture and develop the patient–physician relationship remotely, particularly with new patients. Another reported drawback was reduced interactions among professionals, which had a negative impact on team building and hindered discussions of complicated cases.
Particularly in Quebec, challenges with video consultations were experienced due to lack of equipment (e.g., webcam) or insufficient internet bandwidth in some office settings that resulted in poor audio-visual quality. In Massachusetts, while this was not reported as a barrier for physicians, some said it had been a barrier for their patients. The effort required to install or set up video devices complicated the use of telehealth. Installing an application or looking for equipment needed to obtain care via telehealth were specifically mentioned as challenges for patients. In Massachusetts, some respondents said they had developed “workarounds” that were easier to use than the telehealth systems provided by their institutions.
IV. Positive and negative implications related to relational dimensions of care
This theme addresses the challenges related to the relational aspects of medical telehealth practice. Table 5 presents representative quotes from interviews in both sites that support each subtheme associated with the relational dimensions of care.
In both contexts, the positive aspects of video consultations included patients’ comfort as well as providers’ being able to observe patients, their home environments, and their facial expressions. The fact that patients were usually in the comfort of their homes during telehealth appointments appeared to complement the advantages of physicians being able to observe patients in their home environments; this latter point was particularly noted by Massachusetts physicians. Moreover, seeing patients’ facial expressions was perceived to facilitate communication and contribute to developing or maintaining positive therapeutic relationships.
Negative aspects included the difficulty of maintaining the therapeutic relationship, limited patient engagement, and changes in patients’ expectations. Regardless of the telehealth modality (telephone or video), our results suggest physicians were concerned about the lack of direct human contact, which made it difficult to foster the therapeutic relationship. Although respondents acknowledged that face-to-face appointments and physical examinations were unnecessary to diagnose many conditions (see section on efficiency of care delivery), they viewed them as a major element of their practice and important for establishing trust and relationships with patients. This was reported to be particularly true for new patients or those in need of substantial psychosocial support.
Poor patient engagement was also reported as a telehealth challenge, seen in areas such as providers’ inability to reach patients (e.g., when patients would not answer the unidentified number) or reduced confidentiality of consultations (e.g., patients in public places or driving). For instance, respondents from both sites associated poor patient engagement with distractions caused by situations such as conducting their medical visits in inappropriate places (e.g., at a grocery store) or while driving. Finally, respondents from both sites were concerned that patients would expect more frequent consultations and communications because of their perceptions that telehealth made it relatively easy to contact their physician.