Perceived Impact of Virtual Visits on Access to Care in Family Medicine During the COVID-19 Pandemic: A Qualitative Study of Benefits and Challenges

Abstract

Background:

The COVID-19 pandemic in 2020 led to the rapid adoption of telemedicine, including virtual visits, to minimize face-to-face contact between clinicians and patients. Family medicine clinics across the nation had to transform how they provided primary care while maintaining the core values of family medicine. The objective of this study was to analyze how family medicine faculty perceived the impact of virtual visits on patient access to care.

Methods:

This qualitative study took place in an academic primary care setting. We interviewed clinical faculty who utilized virtual visits about their experiences from June to December 2020. We used qualitative content analysis to evaluate the results of the interviews.

Results:

The study included a total of 20 participants. The mean age was 43.4 years, and 85% of participants were female. Researchers developed 3 themes, “Logistics of virtual visits,” “reigniting the concept of home visits,” and “barriers and benefits that affect specific patient populations” that describe how virtual visits have impacted patients’ access to care. The results highlight how virtual visits improve access to care by increasing flexibility for patients and providers and provide a new perspective into a patient’s home life. Challenges of virtual visits include language barriers, technological issues, and issues unique to vulnerable patient populations.

Conclusion:

Virtual visits can enhance family medicine’s ability to provide accessible care, but there are concerns it may worsen health disparities. Further research and quality improvement projects are needed to examine ways to implement innovative care delivery solutions to avoid further exacerbating these disparities.

Introduction

Since the novel coronavirus disease 2019 (COVID-19) pandemic, outpatient clinics across the United States have had to radically and quickly adapt how they provide patient care.^1,2 When health care systems implemented social distancing measures, the number of in-person appointments was dramatically restricted to help prevent disease transmission.^3,4 Out of necessity, telemedicine quickly expanded to maintain a continuum of healthcare for patients.^{5 -7} Telemedicine refers to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. ⁶ The rapid adoption of digital tools and technologies to implement telemedicine has helped lessen the transmission of the virus, protecting health care professionals and patients from exposure.^3,8

While telemedicine technology and its use are not new, widespread adoption beyond simple telephone correspondence had been relatively slow before the pandemic. ⁹ One significant barrier was telemedicine’s legal and regulatory infrastructure, including liability, cross-state licensing, and cross-hospital credentialing. ¹⁰ In March 2020, the federal government substantially eased restrictions and expanded coverage to include all telemedicine visit types. ¹ This expansion allowed medical specialties to adopt virtual visits quickly when outpatient volumes declined. Telehealth visits, also known as virtual visits, require the health care provider to use an interactive audio and video telecommunication system that permits real-time communication between the distant site and the patient. ⁶ Different medical specialties adapted virtual visits to suit their patient’s unique needs, including family medicine clinics.^2,11,12

Family medicine clinics are in a unique position to offer virtual visits because of the diversity of services provided and patients seen. The comprehensive scope of caring for the entire family over time within the context of their community, regardless of socioeconomic status, location, or language, positions family physicians and their inter-professional care team as the first point of contact with the healthcare system. ¹³ The rapid adoption of virtual visits has challenged family physicians to adapt these core values of family medicine (contextual care, continuity of care, access to care, comprehensive care, and care coordination) within telemedicine. Virtual visits have been associated with high patient satisfaction, better access to care, and overall cost savings.^{14 -18} However, barriers to virtual visits may exacerbate health inequities—virtual visits require access to the internet, an internet-capable device, and sufficient technology literacy which may disproportionally affect under-served communities.^{18 -20}

Virtual visits have remained a standard component of patient care even as most services returned to in-person. As virtual visits become a regular part of care after the COVID-19 pandemic, a better understanding of family physicians’ and team members’ perspectives, and the various challenges they face in adopting virtual care, is necessary. The objective of this study is to use qualitative data to analyze how providers (family physicians and psychologists) at an academic family medicine clinic perceive the impact virtual visits have on access to care amongst the diverse populations they serve.

Methods

Reporting for this study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. This qualitative study took place at the University of Utah (U of U) Health System between June and December 2020. During this time, U of U Health providers rapidly implemented virtual visits for most types of care, and in-person visits were limited for all other types of care to maintain COVID-19 guidelines. The research team consisted of family medicine physicians and a family medicine clinical psychologist (TH, STS, KTF, and JN), an experienced qualitative researcher (DO), and graduate public health research assistants (EG and CT).

Study Design

A constructivist approach was utilized for this qualitative study due to the exploratory nature of the topic. ²¹ Interviews, or one-on-one conversations about the selected topic, were the preferred method in this study to allow participants more privacy. The interviews were conducted virtually to support a higher response rate, reduce barriers to participation, and to follow pandemic safety guidelines. The University of Utah Institutional Review Board (IRB #00133384) exempted this study.

Study Sample and Recruitment

The research team utilized purposive sampling, and eligible participants were clinically active faculty involved with the University of Utah Family Medicine Residency Program who utilized virtual visits because of COVID-19. Participants were recruited via email and through verbal announcements within faculty-wide meetings. In total, 25 participants were eligible and 20 individuals participated in this study (80% participation rate).

Data Collection

The research team developed a semi-structured interview guide to facilitate the interviews. The questions were designed to understand medical providers’ experiences with virtual visits, especially regarding the provider-patient relationship. All interviews were conducted by DO. No repeat interviews were conducted. The interviews were conducted virtually via Zoom and lasted about 30 min. Interviews were audio and visual recorded and then transcribed verbatim. Participants also completed a short survey about their sociodemographic information. Data is available upon request from the corresponding author (TH). The data are not publicly available due to their containing information that could compromise the privacy of research participants.

Data Analysis

Evaluation of the interview results occurred through inductive qualitative content analysis.^22,23 First, the transcribed interviews were analyzed independently by several researchers (TH, KTF, DO, and CT) and coded by category. As researchers uncovered new information, categories were added and edited. After establishing categories, they were organized into themes and subthemes and supported by evidence from the transcripts. The research team discussed these themes and subthemes until they reached a consensus regarding the final results.

Results

Presentation of Results

For reader friendliness, the tables (Tables 1–3) summarize each thematic group by category, and summarize the main findings for each category. In addition, selected quotations are mentioned in the body text. An overview of all relevant quotations and how they informed results can be found in Tables 2A through 4A in the Supplemental Appendix.

Table 1.

Logistics of Virtual Visits.

Category	Result
Time-related	Patients don’t need to take time off work
	Increased flexibility for patients
	Patients save time
Travel-related	Patients don’t need transportation
	Patients don’t need to travel far distances
	Patient Safety
Appointment-related	Increased flexibility for providers
	Increased efficiency for providers
	Value of the physical exam
Location-related	Patients living in shelters lack privacy
	Patients do virtual visits from work for privacy
	Providers tell patients to stop driving during VV
	Patients do virtual visits while exercising

Table 2.

Reigniting the Concept of Home Visits.

Category	Result
Assess home situation	Insight into patients’ home lives
	Insight into patients’ lifestyle (diet)
	Insight into patients’ needs
Deliver and connect services	Insight into patient’s resources
	Improved access to services
Challenges	Home visits are too distracting
	Patients may not be as open on virtual visits

Table 3.

Barriers and Benefits in Specific Patient Populations.

Category	Result
Language barriers	Difficulties using interpreters
	Online patient portals may not have other language options
	Non-English speakers less likely to seek care
Technology barriers	Low SES patients lack access to necessary devices
	Patients with disabilities struggle with technology
	Technology amplifies current disabilities
Barriers for specific populations	Vulnerable Populations—substance use
	Patients with low literacy
	Patients without consistent phone number for virtual visits
Benefits for specific populations	English-speaking patients with digital literacy
	Patients needing behavioral health services or follow-up
	Older adults who are tech savvy

Participant Characteristics

A total of 20 clinical faculty were interviewed, including physicians (n = 19) and a psychologist (n = 1). The mean age was 43.4 years, and 80% of participants were female. On average, participants have been practicing medicine for 14.2 years, but individual time spent practicing varies. Most participants spent at least half of their working time in the clinic (Supplemental Table 1a).

Logistics of Virtual Visits

Table 1 summarizes the categories relating to the logistics of scheduling and conducting a virtual visit. For this analysis, we subdivided the logistics of virtual visits into “time-related,” “travel-related,” “appointment-related,” and “location-related.” Overall, virtual visits increase flexibility, but providers also identified areas of concern where appointment logistics become challenging to address.

Time-related

Providers highlighted that the shift from in-person to virtual visits had allowed patients newfound flexibility with appointment scheduling. Patients no longer have to take as much time off work and logistically do not have to spend as much time getting to their appointment. Furthermore, this time flexibility allows patients with complicated social situations, such as single parenting, to accommodate appointments more easily.

When people are working like multiple jobs, or for single parents . . . it’s just a lot easier for them to navigate instead of bringing their kids everywhere [I12: 312-317].

Travel-related

Overall, providers viewed the reduction in patient travel needs as a substantial benefit for patients. They noted an overall improvement in accessibility by reducing driving time. In particular, providers noted benefits for patients from rural communities who would typically have to drive several hours to seek medical care or drive in winter weather conditions.

I think it gives more accessibility for patients from everywhere to reach out to you. So transportation is not an issue. . . .they wouldn’t have to take the bus in the middle of the winter [I15: 371-374].

Appointment-related

Providers spoke positively of increased flexibility with virtual visits, noting the benefits of being able to convert their clinic to virtual if needed. They also described increased efficiency in the visits regarding patients’ focus.

[Virtual visits] for the most part are actually quite a bit faster. Oftentimes, I think just the majority of [patients] seem a little bit more focused a little bit quicker. And in part I suspect that could be just because there’s fewer kind of transitions [I13: 269-273].

However, they also lost out on the physical exam and the ability to use multiple senses to evaluate patients. As pointed out by the participant below, physicians are trained to utilize all of their senses during an exam.

You can’t do a physical exam and like I was trained on using all my, my senses. And I do, I actually do, like I listen, and I touch. You know, I percuss [I15: 392-393].

Location-related

Virtual visits have allowed providers to see patients in various locations, including where patients lived, worked, and exercised. Providers raised concerns about patient privacy in multiple settings, including the lack of privacy for patients living in shelters. In contrast, work environments provided others with more privacy. Another common location was in the car, prompting providers to request that patients be parked and not actively driving.

A couple times. I’ve had to say, Stop your car. Okay, we’re not doing this now, I’m not going to be the cause of an accident or anything else [I16: 408-410].

Reigniting the Concept of Home Visits

Table 2 summarizes the ways virtual visits have acted as a modern version of the home visit. Categories for this thematic area included providers’ ability to assess a patient’s home situation, unique ways to deliver care and connect patients to services, and the associated challenges. Providers described multiple benefits that enhanced insights into patients’ home environments and limitations associated with the different visit settings.

Assess home situation

Providers explained how their increased ability to assess the patient’s home environment improved their insight into patients’ lives. For example, they described the value of knowing if a patient’s environment is more chaotic than they would have guessed from the patient’s presentation in the clinic.

I have gotten to hang out in their own room while they play at their train table, and watch how they are in their home environment. And it’s just really lovely [I4: 314-316].

Additionally, providers appreciated gaining an enhanced understanding of the patient’s socioeconomic status. They also noted increased insight into patients’ lifestyles, for example, by viewing what food was accessible.

Deliver and connect services

According to providers, the virtual visit provided unique ways of assessing patients and their resources in their home environment. One provider described having a patient provide readings from a home blood pressure monitor.

What have your blood pressure readings been? And she said, Oh, let me go grab my machine [I8: 228-229].

In another example, a provider reported coordinating home-bound patient visits with home health services so that the provider could observe and examine the patient’s wound. The virtual visit acted as the catalyst for these unique opportunities to coordinate care with multiple entities and technologies.

Challenges

Providers described unique challenges and annoyances with virtual visits. Providers sometimes felt patients acted too casually and were moving around throughout the visit, or not focusing on the provider due to interacting with someone off-screen. They also noted that the home environment could limit open communication if the patient lacked privacy, as described in the quote below.

I think people are less inclined to open up about like how they’re really feeling. . . I had a patient tell me that she didn’t want to do virtual therapy anymore, because she didn’t feel like she could really tell her therapist, what was going on with her over a zoom call [I7: 153-156].

Barriers and Benefits in Specific Patient Populations

Table 3 summarizes the barriers and benefits of virtual visits among specific patient populations. We identified language and technology-based challenges, certain populations with additional barriers to virtual visits, and patient populations who benefit from the expansion of the virtual environment.

Language barriers

Virtual visits were typically performed through an encrypted server, including 1 server integrated with the electronic medical record. Providers noted that the online patient portal only has English as a language option. Patients previously also had in-person or audio interpreters at each visit, but adding a virtual visit complicated the logistics. Overall, providers were concerned that non-English speaking patients were less likely to seek care.

We’ve had to do a lot more with our patients who needed interpreters, that’s been kind of one of the biggest challenges is figuring out how to do that in a virtual visit. And honestly, it doesn’t work very well. And we tend to just try and do in person for them [I18: 258-261].

Technology barriers

Virtual visits require a device that allows a camera, microphone, and connection to data or the internet. Patients from lower socioeconomic backgrounds may not have the necessary equipment for virtual visits. Providers noted people with cognitive disabilities also needed additional assistance to navigate the process of a virtual visit. Furthermore, virtual visits amplified barriers to access for other types of disabilities; for example, technological barriers experienced by people who are hard of hearing.

Lower socioeconomic status patients who don’t have computers, iPads, all of that. We’re probably not seeing them. Why do you think that? Because they don’t have it’s not as easy for them to access technology, or they just don’t even realize it’s an option [I8: 170-172].

Barriers for specific populations

Virtual visits can be challenging for specific patient populations due to issues with access to technology, digital literacy, or the logistics of scheduling an appointment. These challenges affect vulnerable populations such as people with substance use disorders or unstable housing. Individuals without consistent phone numbers can also be challenging to reach for a virtual visit.

More vulnerable populations. . . I do a lot of substance use treatments. Like medication assisted treatment where I feel like I’ve lost a good number of them, because we just can’t consistently connect with them [I12: 348-350].

Benefits for specific populations

Providers explained that some types of patients, or patient concerns, are better suited for a virtual visit in contrast with others who may experience challenges. Providers described patients who may benefit the most from virtual visits as those who are English-speaking with digital literacy, including older adults who have been very adept. Also, patients with specific behavioral health needs who didn’t require a physical exam benefited from virtual visits.

I think for follow up and for behavioral health, and for counseling on maybe, you know, a lab or new diagnosis where I don’t have to do a physical exam, it’s ideal [I20: 161-163].

Discussion

This qualitative study highlights the unique perspective of family medicine providers on how virtual visits have impacted patients’ access to care. Providers discussed 3 critical themes regarding how virtual visits have impacted access to family medicine practice: first, the logistical aspect of accessing appointments (time, travel, safety, and flexibility), second, a re-ignition of the concept of home visits and insight into patients’ private environments, and third, challenges within vulnerable populations.

Regarding how the transition to virtual visits have influenced the logistics of a medical appointment, providers valued the increased flexibility and efficiency for the clinic and patients, particularly for behavioral health-focused visits, and noted the benefits of added insight into their patients’ home environments. Prior to the pandemic, evidence was emerging that patients and providers enjoyed the convenience of virtual visits without sacrificing the quality of care they received in-person.^{24 -26} However, our analysis and the work of others has revealed that making blanket statements about access to telemedicine is risky, because different groups of patients have different experiences with the processes and parameters of meeting virtually. ²⁷

Historically, home visits have served a critical role in patient care, particularly in supporting the needs of geriatric populations. ²⁸ Providers perceived these visits as particularly useful in evaluating home safety and patients with polypharmacy/multiple medical concerns. ²⁹ However, home visits are now much less common, with barriers related to high patient load, inadequate reimbursement, and liability and safety concerns. ³⁰ The results of our analysis revealed that virtual visits have the potential to provide many of the benefits of home visits, such as reducing access barriers for patients and enhancing understanding of the patient’s home environment without the added time and other requirements of in-person home visits.

However, virtual visits have barriers limiting the population of patients who effectively participate in these appointments. Providers noted discrepancies in their patients’ ability to access these visits. In particular, providers worried that patients who did not speak English, had disabilities impacting their ability to use technology, or were from lower socioeconomic backgrounds faced more barriers with virtual visits. Previous studies have also found that telemedicine has worsened health care disparities due to difficulty accessing care (eg, people of color, non-English speakers, individuals with substance use disorders^{31 -33}). In particular, satisfaction with and use of virtual visits has been mixed among older adults.^34,35 Given the evidence that many patients, including those from disadvantaged backgrounds, prefer to be able to access virtual visits medical providers and healthcare systems must continue to work to enhance equity across this platform.^36,37

Limitations

A limitation of this study is that recruitment occurred at a single healthcare system in 1 state; this limitation may impact the generalizability of results. However, participants worked across multiple clinics serving a wide variety of patient populations within this healthcare system. Additionally, participants were interviewed within the first year of the COVID-19 pandemic, and technology has continued to evolve in the time since.

Conclusion

There is a great expectation that telemedicine will continue after the COVID-19 pandemic, as it is efficient and cost-beneficial for patients and health care systems. ³⁴ This study demonstrates a balanced view of medical providers’ perspectives on the benefits of virtual visits, with concerns over the potential worsening of inequity. Future research and quality improvement projects should continue examining means of harnessing telemedicine’s many benefits while ensuring that all patients have equal opportunities to access these services.