Table 4.

Impact of workflow and technical challenges on patient–provider relationship.

Themes and sub-themes	Illustrative quote
Telehealth removed face-to-face interaction from telephone only visits. a. Inability to understand what is going on with the patient.	“You lose a lot of the nuances of what you would get if you saw that person in person. And, you know, certainly the physical exam part is extremely limited and much harder to accomplish. So I think that's the part I hate, is the lack of ability to actually do a good exam and physically touch, and, and see the patient. I think you lose a lot of sense of clarity on dog with the patient by doing it via telephone.” (Provider, Large Independent Practice)
b. Patients’ doubt about provider's capacity to provide care via telephone visits	“People were like, ‘No, I need to be seen.’ So, at the beginning it was okay, but like a couple of months down the road, no, I need to be seen, this needs to be addressed. I can't do it on the phone. How can you treat me, you know, those questions became involved, so we had to start seeing more people on site.” (Chief Medical Officer, Small Independent Practice)
Telehealth impacted new patient–provider relationships	“We've had staff turnover and they have never met the person that they're interacting with. Whereas before the patients had pretty strong relationships with the MAs, the nurses and clinicians. So in the course of this, as we had some shifting around a staff, like I, I left the XX clinic entirely. So there's a whole lot of patients who I used to see in XX clinic who have a brand new clinician, a new nurse and an MA they've never met, and they've had maybe a couple, maybe one in person visit for some sick visit and some tele visits. That's a really different relationship.” (Medical Director, Federally Qualified Health Center)
Telehealth hampered trust for both providers and patients. a. Overreliance on patient’ description of symptoms	“I had a couple of rashes that I remember seeing, and the video quality was not good up close. It was great for seeing face to face, but like, when they'd show me stuff, it was nothing but a big, pink blur. And even when they tried to take pictures, patients are not good at taking pictures, and it would be, like ultimate flash, so nothing but a shine, and so it would be hard to figure out what rashes were. I would generally kind of have to just do the best I could, based on their description of things which is frustrating.” (Provider, Small Independent Practice)
b. Perception of provider incompetence	“There were so many other times that you were dealing with so much frustration. Patients yelling at you about not wanting to come in, but they still wanted you to prescribe their medicines, even though they needed lab work, that it would get very, very frustrating.” (Provider, Health System)