Learning from patients about their experiences with early adoption of virtual care appointments in primary care in Ontario, Canada during the COVID-19 pandemic: a qualitative study

Abstract

Objective

The objective of this study was to examine patient experiences with virtual (telephone and video) encounters in primary care and make recommendations to inform the broader adoption of virtual care.

Design

A descriptive qualitative study using semi-structured interviews for data collection.

Setting

Ontario, Canada.

Participants

Fifty-five primary care patients across Ontario, Canada, who had experienced at least one virtual (telephone or video) encounter with a healthcare provider in primary care, participated in semi-structured individual interviews conducted between 15 January 2021 and 22 March 2021.

Results

With respect to patients’ experiences with virtual care appointments, we identified the following seven themes: (1) Enhancing access, (2) Importance of patient-provider relationship, (3) Active communication and attunement, (4) Assuring privacy and confidentiality, (5) Shorter appointments, (6) Asynchronous technologies being underutilised and (7) Strengthening the future of virtual care. Despite the rapid adoption of synchronous virtual care, participants generally reported positive experiences. Virtual care enhanced access to care and was overwhelmingly supported for continued use. While new patient-provider relationships faced challenges, pre-existing, positive relationships thrived. Concerns about the shortness of virtual care appointments were reported.

Conclusions

Virtual care offers a promising modality for patients to experience care. Moving forward, primary care practices should consider expanding options for asynchronous virtual care, consider the length of virtual care appointments and offer patients greater choice in the modality of their care appointments.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Data collection occurred in both English and French.

• Participants varied by age, gender and race and had representation across geographical regions of Ontario, Canada.

• No inclusion of the perspectives of care providers who serve an essential role in the care experience.

• Our sample represents experiences of patients with primary care in Ontario, Canada, so may not be indicative of experiences across all primary care settings.

Introduction

The distancing measures instituted to mitigate the spread of COVID-19 required primary care practices to rapidly adopt synchronous virtual care (telephone and video) appointments to deliver clinical care.¹ Virtual care is defined as “any interaction between patients and/or members of their circle of care, occurring remotely, using any form of communication or information technologies, with the aim of facilitating or maximising the quality and effectiveness of patient care”.² During the early phases of the COVID-19 pandemic in Canada, virtual care was predominantly delivered through telephone visits, with video used less frequently, following the introduction of remuneration policies to support primary care consultations.³ In Ontario, Canada’s most populous province with 14.7 million residents, the use of virtual care for ambulatory care visits increased from 1.6% in 2019 to 70.6% in 2020,^{4 5} and primary care visits increased by 56-fold.⁶ This rapid and marked shift to virtual care occurred with minimal preparation and training for healthcare providers, reflecting the sudden and significant changes in the delivery of primary care services experienced by patients.⁷ Across primary care settings, virtual care has persisted as a legacy of the pandemic, yet the rapid speed at which health services were reorganised meant that perspectives of primary care patients and the public were seldom incorporated.^{3 8}

Since 2020, research has been conducted with primary care physicians and healthcare providers to understand their experiences and evaluate the virtual care within their practices.^{5 9} Multiple such studies noted the effectiveness of virtual care appointments and supported the continued use of telephone and video appointments beyond the pandemic years.10,14 Certain types of appointments, including lab reviews, mental health counselling, care plan discussions and medication refills for chronic conditions, were considered to be well-suited for virtual care from the perspective of primary care physicians.^{10 15} Additionally, in comparison to in-person appointments, virtual appointments were found to be equally effective for certain types of encounters including providing mental health supports, smoking cessation interventions and responding to concerns related to patient alcohol use.¹⁶ Primary care providers have appreciated the opportunity to observe patients in their home environments, which may increase patient comfort and ease during a virtual appointment.^{10 13 17 18} However, physicians and other members of the primary care team have raised concerns regarding the lack of physical contact and personal connection which may impede rapport-building with patients during virtual encounters, and may hinder primary care physicians’ ability to conduct physical examinations.^{10 19} Physicians also raised some concerns about the privacy of the patient’s environment and how this might impact the quality of the care.¹⁸ Some primary care physicians noted the positive impact of using virtual care on their well-being. For example, primary care physicians in Sweden expressed that virtual care offered flexibility with their work¹³ while primary care physicians in the US agreed that virtual care offers greater convenience and accessibility.¹⁸ However, primary care physicians expressed concerns that using virtual care can sometimes lead to blurred boundaries between their work and non-work life.¹⁸

Research investigating patients’ experiences of virtual care across healthcare settings has been increasing.³ For example, in a study of over 48 000 patients across 12 countries, there was high satisfaction across all types of virtual visits with noted benefits of saving time from less travel and waiting, increased accessibility, enhanced convenience and cost efficiencies.²⁰ Benefits such as less travel, less time off work and greater convenience were also found in studies focused on an older population group and in rural population groups.21,23 While virtual care offers increased access and convenience, both patients and physicians shared concerns about technological barriers such as lagging technology and insufficient technical support.^{14 24 25} Another study of primary care patients in Ontario highlighted the effectiveness of virtual care with 82% of patients perceiving virtual care as the same or better than an in-person visit.²⁶ In a New York City-based study, virtual appointments by video were found to have parity with in-person appointments and there were no statistically significant differences in scores rating the likelihood for recommending the practice to others, quality of time spent with the physician and how well care was explained.²⁷ Virtual care was also seen to reduce the burden on patients by improving continuity of care and the experience of care, and facilitating access to information and support for chronic disease management.²⁶ Studies on the impact of virtual care on primary care patients found that communication between patients and physicians changed as virtual visits generally became shorter and more rushed, and patients found themselves having to advocate for themselves more.^{18 28 29} Patients in these studies also shared that an existing relationship with a physician helped with the transition to virtual care, and it was important for patients to have more choice regarding virtual modalities.^{18 28}

Although much is known about the challenges and opportunities of virtual care for providers and practices,^{3 4 6} much less is known about the patients’ experiences in primary care with these modalities.⁷ Given that the widespread adoption of virtual care is expected to continue and likely to grow, there is an imperative need to understand patients’ expectations and experiences with telephone and video encounters from the onset of implementation. The experiences of patients exposed to virtual care modalities will provide indispensable insights to inform the broad scale adoption of virtual care. The purpose of this study was to examine patient experiences with virtual (telephone and video) encounters in primary care across Ontario, Canada and make recommendations to inform its broader adoption. The following research question guided this study: what are patients’ experiences with virtual encounters (telephone and video encounters) during the COVID-19 pandemic?

Methods

A descriptive qualitative research design guided the development of the qualitative study presented in this manuscript.³⁰ Our interdisciplinary research team was comprised of members representing diverse clinical and disciplinary backgrounds spanning primary care, social work, epidemiology, pharmacy, rehabilitative sciences and health services delivery research. Knowledge users on the research team represented the Association of Family Health Teams of Ontario (AFHTO) and the Alliance for Healthier Communities (Alliance). Research ethics approval was obtained from the University of Toronto (#40046) and the Bruyère Continuing Care (#M16-20-065).

Study context

Nearly 75% of patients in Ontario are enrolled with a primary care provider located in physician-only or interprofessional team models of primary care.³¹ On 17 March 2020, the government of Ontario declared a state of emergency, which required the closure of most indoor businesses and facilities except those providing essential services.³² Near the end of the first wave of the COVID-19 pandemic, Public Health Ontario reported a total of 34 911 cases of COVID-19 and 467 000 during the third wave.³³ Because of the requirement for physical distancing, there was a dramatic shift in the delivery of primary care across Ontario, from mostly in-person prior to the pandemic to mostly virtual appointments post-pandemic.^{9 34}

Sample and recruitment

A purposive sampling technique was used to recruit eligible participants, which included individuals over the age of 18 years old who had at least one appointment by telephone or video with a primary care provider in the province of Ontario since the start of the pandemic (March 2020). Recruitment began in January 2021 and ended in March 2021. We sent targeted emails to a broad range of patient and community organisations and advertised broadly on social media (ie, Facebook, Instagram, X/Twitter). In addition, members of our research team and Patient Advisory Committee also shared recruitment information about the study with their networks. The knowledge users on the research team – AFHTO and Alliance - assisted with recruitment by sending emails to their membership about the study to primary care providers who were invited to share the study information within their practice. Potential participants then contacted the research coordinator (SL) or Principal Investigator (RA) to express interest in participating in the study. In addition, our team was simultaneously conducting an online provincial-wide cross-sectional population-based survey evaluating patients’ experiences with virtual care, and the survey included a question inviting those interested in being contacted about a potential interview to self-identify by providing their contact information. Potential participants who provided their contact information in the online survey were contacted by the study coordinator (SL) who then provided more information about this qualitative study. The recruitment email included an information sheet that was approved by the Research Ethics Boards which explained the study goal, methods, and the name and contact information of the principal investigator (RA) and project coordinator (SL). Recruitment information was disseminated in both English and French languages. We provided an honourarium of a $20 gift card to all participants.

Data collection

Data were collected using individual one-on-one interviews that were conducted by telephone or through an online video platform (Zoom), based on participant preference. Qualitative studies have previously used telephone and/or video for successful data collection.³⁵ A semi-structured interview guide, informed by the literature and developed by our team, with input from our Patient Advisory Committee, guided the individual interviews (see online supplemental file). The interview guide included questions on participants’ history and experience with telephone and video appointments, and recommendations for the future use of virtual care.

Trained qualitative researchers conducted the interviews by telephone or video, based on participant preference. Each interview was audio recorded and professionally transcribed verbatim. Participants were assigned an anonymised code to promote confidentiality. Interviews were conducted in Canada’s official languages - English or French - based on the participants’ preference and spanned between 10 min and 57 min in length. Although there was one 10 min interview, most of the interviews were close to 1 hour in length. Field notes were made immediately following each interview. From 15 January 2021 to 22 March 2021, we conducted 55 semi-structured interviews with primary care patients across Ontario, Canada. Participants were sent a consent form via email to review and sign and return to the project coordinator (via email or mail) prior to the individual interview commencing and were given the opportunity to ask questions before the interview commenced. All participants provided informed consent.

Data analysis

Data collection and data analysis took place simultaneously, with data analysis following an inductive thematic analysis approach.^{36 37} Thematic analysis is a process that involves the search for themes that emerge as important to the description of the phenomenon.^{36 38} Data were analysed in their respective language of English and French. Two researchers reviewed each transcript as primary and secondary coders (RA/SL and/or AB). The first step was an initial review of the transcripts to develop familiarity with the content and writing initial notes that emerged. Then, the two coders systematically categorised data into initial codes. The third step consisted of refining codes and developing initial themes. Once analysis of all transcripts was complete, themes were reviewed and discussed with the entire research team. Themes were defined and refined, and we identified key quotes that illustrated the nuance of each theme. Lastly, a narrative was developed among the themes during manuscript preparation. NVivo V.12 helped organise the analysis process.

Patient and public involvement

Patient perspectives were included within the research team by way of a Patient Advisory Committee who provided guidance throughout all phases of this study.

Results

There was a total of n=55 participants, with 45 interviews conducted in English and 10 conducted in French. Participants varied by age, gender, race and geographical region (see table 1). Among the 55 participants, 54 (98%) had at least one appointment with a primary care provider by telephone, and 13 (24%) had at least one appointment with a primary care provider by video. The majority of participants (96%) had a virtual appointment with a family physician. However, participants also had virtual appointments with a range of other types of primary care providers (see table 1).

Table 1. Participant demographics: age, gender, race, geographical region, appointment type, type of primary care model, type of provider (n=55).

Characteristics	No. (%)
Age
18 to 24	2 (4%)
25 to 34	9 (16%)
35 to 44	9 (16%)
45 to 54	6 (11%)
55 to 64	14 (25%)
65 and over	15 (27%)
Gender
Female	40 (73%)
Male	12 (22%)
Trans male	1 (2%)
Non-binary	2 (4%)
Race
White	39 (71%)
BIPOC*	15 (27%)
No response	1 (2%)
Geographical region
North	8 (15%)
West	9 (16%)
East	16 (29%)
Central	8 (15%)
Toronto	14 (25%)
Appointment type†
Telephone	54 (98%)
Video	13 (24%)
Type of primary care model
Interprofessional team	29 (53%)
Physician-only	26 (47%)
Type of provider
Family physician	53 (96%)
Nurse or nurse practitioner	12 (22%)
Social worker	4 (7%)
Pharmacist	2 (4%)
Psychiatrist	1 (2%)
Dietitian	1 (2%)
Physical therapist	1 (2%)
Psychologist	1 (2%)

^*BIPOC=Black, Indigenous, person of colour.

^†Some participants had both telephone and video appointments.

Reasons for patients’ virtual appointments spanned preventative care, new concerns, chronic conditions and even some urgent concerns. Prior to the COVID-19 pandemic, participants did not experience virtual care appointments in primary care, other than the occasional after-hours urgent call: “I’d never had an appointment with (my family physician) by phone” (P04).

With respect to patients’ experiences with virtual care appointments, we identified the following seven themes: (1) Enhancing access, (2) Importance of patient-provider relationship, (3) Active communication and attunement, (4) Assuring privacy and confidentiality, (5) Shorter appointments, (6) Asynchronous technologies being underutilised and (7) Strengthening the future of virtual care.

Enhancing access

Participants overwhelmingly indicated that virtual appointments, both telephone and video–enhanced, provided access, in part because of the comfort and convenience, particularly during the pandemic. One noted, “What worked well was that I didn’t have to go in…I felt comfortable. I was able to access the help, whereas I might have stayed home and not called her at all, if I didn’t have that available” (P17). Virtual appointments saved patients’ time and energy: “It’s very efficient in terms of time…everything gets done a lot faster and more efficiently” (P21). Participants also appreciated that virtual appointments saved them money. For example, “Given my absolutely abysmal low income right now, every bus trip is an expense that unfortunately means something to me, and it’s nice not to have to worry about… do I have enough bus fare” (P37). Additionally, it was easy to integrate virtual appointments within participants’ daily schedules: “It was easy to fit into my schedule around other things. So those kinds of accessibility issues are important” (P07). Furthermore, some participants explained that virtual care improved access for patients with mental health concerns, chronic pain and disabilities: “When you’re dealing with mental health challenges and anxiety and stress…making it easier to access help makes it easier to get the help” (P13). Despite the benefits, participants indicated that virtual care was more time-consuming if their problem was unable to be addressed by telephone or video, and the patient was asked to book a follow-up in-person appointment. A patient explained, “So now I’ve kind of wasted time talking to him on the phone and he can’t do anything about it until he looks at it” (P39). Participants also enthusiastically explained that virtual care facilitated access for the involvement of family and caregivers, as noted by a participant: “Virtual care can make it easier for caregivers or family members who want to be involved, or who the patient wants to be involved, or who need to be involved… especially if they live at a distance” (P07).

Importance of patient-provider relationship

All participants emphasised the importance of the patient-provider relationship as a key facilitator of their experience with virtual encounters. A participant explained, “Because I do have a good relationship with my doctor, I believe the care was identical as in-person, virtually and on the phone” (P43). Another participant explained how a long-term relationship helped inform their provider during a virtual appointment: “The fact that my family doctor (and I have) had such a long-standing relationship…and he had what I think is probably from his point of view, a great baseline to work from…I would think initiating a (new) relationship in this manner would be difficult” (P31). Participants raised concerns, however, that virtual appointments were difficult for patients without a pre-existing patient-provider relationship. As noted by one participant who had a sub-par experience with a virtual appointment, “I feel like the ability to establish a relationship or connection to support the conversation is stilted…I hesitate to even call and make any more appointments now” (P08).

The use of virtual modalities may have the potential to strengthen and/or weaken the patient-provider relationship. Interestingly, participants viewed unscheduled telephone calls as a demonstration of providers’ care and concern. A participant explained:

It made me feel that she was concerned and dedicated to my care, that she was taking time that wasn’t scheduled for her or for me, and that she could see that it was important, and it was a priority for me… I was very impressed with her decision to do that…and I thought ‘this is healthcare at its finest’. (P7)

Yet most participants expressed worry that the long-term use of only virtual care might erode the strength of the patient-provider relationship: “It seemed a bit mechanical… I just felt on the phone I felt distance. I didn’t have the same feeling (as if) I was there with him…I would be very concerned if the only relationship that I had with my (family physician) certainly was a virtual relationship” (P31).

Active communication and attunement

Patients highlighted active communication as a technique that facilitated a more effective appointment with their physician. Participants explained that successful communication within virtual appointments required providers to draw on strong interpersonal skills. For example, “The sound of her voice was very like calming and she was very open to questions” (P02). Successful communication for virtual appointments also required additional patient preparation than in-person appointments, as described by one patient: “It was really good communication on both of our parts. I wrote down my questions before I talked to her, before our appointments. And she took the time to answer them all…I was more organised over the phone than I was in person” (P17). Furthermore, several participants highlighted the importance of a patient’s health literacy as a factor contributing to successful communication in a virtual appointment. Participants’ professional background in healthcare enhanced their ability to engage with nomenclature and comprehension. A participant explained, “I’ve worked my life in healthcare, so I’m a little better at translating medical. I think for somebody who might not have had that background, there would’ve been more of a disconnect” (P05). Some participants cited their lived experience with chronic conditions as an important asset for engaging in virtual appointments. For example, “I’ve had so much contact and had to make so many medical decisions pre-COVID-19… So I have a lot of confidence in my ability to take information in over the phone…. “If I hadn’t had that background, I might feel otherwise” (P29).

All participants reported challenges related to the absence of body language, noting that the lack of body language may create challenges with the assessment of some conditions such as acute pain and mental health. A participant noted, “I go back to the information that’s available by seeing somebody in person whether they’re looking you in the eye…what can be gathered from body language and smiles and facial expressions” (P22). Further, participants explained that communication without body language posed unique challenges that need to be considered for virtual appointments. A participant explained, “It didn’t give her (the provider) a chance to provide any visual cues for reassurance” (P05).

Overall, most patients indicated that they did not have difficulties communicating with their provider during a virtual appointment. “I personally didn’t have any struggle with communication. I found that she understood me.” (P04). Most participants described their satisfaction about the quality of the virtual appointment in relation to the provider’s communication. For example, “I felt like it was very similar to what he would say in person” (P02). Some participants reported that the quality of care was better than in-person because the provider was even more attuned to them: “I think it might even be better, because she’s less distracted. And during the phone call, people won’t say, ‘Hey I need this, can you come for a second?’ And she’s focusing on listening to me, so I’m very happy with the result” (P27).

Assuring privacy and confidentiality

Most participants expressed minimal concerns about privacy and confidentiality in their own environment. A participant explained, “He (family physician) asked me to ensure that I was alone, suggested closing the door” (P31). Telephone appointments provided flexibility and assisted patients in finding private spaces at home or elsewhere to take the appointment. For example, “Because I was walking outside, there weren’t that many people around. I sat down on a park bench and felt very comfortable talking with her about these personal concerns” (P07). The few participants who did report privacy and confidentiality concerns in their own environment indicated that they were restricted with how forthcoming they were in speaking openly with their provider. One patient explained: “There was…roommate tensions happening…So I was definitely very conscious when I was there about kind of the things I was saying, because our rooms were right next to each other, so that made it a little bit uncomfortable” (P41). Interestingly, participants wanted assurance that their provider was in a private and confidential space, as explained by a participant: “I want to know if someone else is present. That’s the thing that’s important to me, my ability to give consent…so I am very concerned about having a call with my doctor and maybe having residents or…anybody else in their room” (P4).

Shorter appointments

The majority of participants described virtual appointments as being shorter and more rushed than in-person appointments. Some participants noted that their issues were inadequately assessed and/or treated because they were unable to tell the provider the full details about the condition. A patient noted, “They try to limit the calls to within ten minutes…if I’m trying to explain, two or three min I take to explain…the symptoms. “By then, she has already made up her mind. This is what you should do” (P10). Additionally, many participants reported that they disliked that they were unable to talk about the range of topics that they usually would discuss at an in-person appointment, and instead, the discussion was limited to a specific problem focus. One patient mentioned how some issues can be missed due to virtual appointments feeling rushed:

A resident once mentioned that a certain count of my bloodwork came back pretty abnormal, and it had been abnormal for months, and my doctor just hadn’t mentioned it. But then, those things kind of fell to the wayside in other appointments, because it didn’t feel like the most pressing thing, and the phone appointments feel like it’s kind of has to be the most pressing thing, because it’s kind of quick. They’re fifteen-minute slots. (P41)

Asynchronous technologies being underutilised

The limited use of asynchronous virtual care options during a time of physical distancing created a burden for some patients. Across several interviews, participants explained that they were required to travel to their primary care clinic in order to pick up documents following a virtual appointment with the primary care provider. A patient explained: “The part that was hard for me to grasp was that I had to…go to the office to pick up requisitions. I had to go to the office to pick up results… they should have been routed electronically… The burden of care shifted to us for that particular regard” (P08). Many participants reported a desire to have mechanisms for asynchronously sharing information before and/or after appointments, for example, by email, patient portal or through another means. The type of information that participants wanted to share in advance of a virtual appointment included photographs of a problem area on their body; documents, including reports from other healthcare providers; contextual information of a health issue and a list of agenda items that they wanted to discuss with the provider during their virtual appointment. In addition, participants wanted providers to send documents electronically following an appointment when needed. One participant noted:

If you have concerns about symptoms that you can share either a photo of a rash, for example, or you could share a photo of an incision…that you’re monitoring…this is what it looks like today. It’s getting better than it was, like post-op or something, right? I think those would be things that would be – might be great screenings as well, appointments. (P13)

Some participants highlighted that the use of asynchronous methods of information sharing, like the use of secure portals or email to share photos, documents or appointment agendas, contributed to a positive experience. A participant provided an example of how asynchronous sharing of photos was instrumental to assessment and coordination and prevented them from having to go to their local emergency room:

I fell off the deck onto a cast iron patio furniture…I was bleeding all over the place. I didn’t know whether I should go to the hospital or not…my wife…started to panic. We got hold of our doctor…and he said, you’re going to have to go to emergency…I said, I really don’t want to…what if we take some video or pictures? So we sent them…they could see the cuts were quite deep, needed attention. So my doctor ordered a nursing room chair…the specialised bandages…a wound nurse….Because of electronics and video and pictures and phoning, they kept me out of the hospital. (P38)

Strengthening the future of virtual care

Virtual care as an option, not a replacement

Many participants noted that they desired the ongoing option for virtual care and wanted virtual care to continue, as highlighted, “I would be totally satisfied with continuing with the (telephone appointments) and on request, do the in-office appointments. Most of the time, I think the phone appointments are great” (P03). Another patient felt similarly, “I think whatever it took to prompt this shift in care delivery shouldn’t be rolled back” (P06). Most patients expressed an interest to have a combination of virtual and in-person appointments, as described by a participant, “I would say an 80/20 split. 80% phone and 20% in person… Because most of the things that I had been going to see the doctor about, we could have done on phone or video” (P40). A few wanted the occasional use of virtual care when the usual in-person care is unavailable, such as for after-hours urgent care. “If it were a case of an after-hours emergency call where you’re trying to get some advice on whether to go to the emergency department…I would use it under those circumstances. But no, I wouldn’t request the telephone appointment otherwise” (P22). Most participants reported that they want in-person appointments when there is a need for the provider to do a physical assessment that requires touching a person’s body. A patient explained, “If I’m describing a pain, like my abdomen, I think it would be appropriate for them to physically, like, touch my stomach and feel where I’m saying I’m having that pain, vs me somewhat describe it on the phone. So that would be more appropriate in person” (P14). Alternatively, a few participants only wanted in-person appointments and had no desire for future virtual appointments. One participant noted, “They may be very necessary (during COVID-19) but an inferior substitute for in-person visits” (P36). Another participant explained, “The less (video appointments) I can have, the better. I don’t love it. For her (family physician), I would go and park my car and pay for parking, to have that contact” (P15).

Determining the type of modality

Providers’ preference often determined the type of technology used (telephone or video), as one participant noted: “I do the appointment with my nurse and dietitian by video simply because they prefer it” (P29). Providers’ typically offered telephone appointments as the main modality for virtual appointment, as explained by one participant: “Since March, it’s been only telephone appointments” (P10). There were often two reasons for the use of video instead of telephone. First, when patients specifically requested it as explained by a participant, “I’m always the one that has to mention it and to ask for it (video appointment)…I think she is just set in her ways” (P34). Second, providers recommended using video when they wanted to do a visual assessment: “It was a video as opposed to simply a phone call because he wanted…to look at the lesion from different angles…using the video was very effective” (P31). To strengthen patients’ experience with virtual care going forward, participants recommended that patients have greater input in choosing the type of modality used for their future appointments. A participant elaborated: The word “choice” is really key for me, that it should be a decision between the care provider and the patient how that care is delivered…. In future, I think the choice aspect needs to be considered really carefully so it’s not shifting the hierarchy even more than it normally would be toward the care provider” (P07).

Advancing virtual care with guidelines and education

All participants provided suggestions on how to improve virtual care, notably through guidelines and education. First, participants recommended developing standards for virtual care. One participant noted, “I think we need to have some kind of guidance for everybody, because standards are something” (P01). Participants explained that standards or guidelines would help foster continuity across providers in how virtual care is used: “I hope that all of the doctors are consistent… If I virtually interact with one doctor and then interact with another and I get two different things, then it’s like really confusing or makes me really confused” (P02). Second, participants noted the need for education and training of both providers and patients on how to nurture optimal virtual encounters. For example, a patient explained: “All professionals need to have better training in (virtual) communications, learning how to communicate effectively” (P06). Another participant stated: “I think patients really need to have education and support to make the virtual care system successful” (P07).

Discussion

This study comprised an exploration of patients’ experiences with the use of virtual care in primary care. Considering Bell’s statement that tells us that “policies are rarely fully formed when implemented” (p.10),³⁹ it is worthwhile to undertake this study given the rapid implementation of virtual care with limited patient input. Health systems can move quickly past crisis periods without fully integrating lessons learnt. By sharing primary care patients’ experiences with virtual care from the early phases of the pandemic, our study functions as institutional memory that facilitates reflective learning and provides some key considerations for patient-centred virtual care going forward. The experiences shared by patients through individual interviews enabled an in-depth understanding of patients’ experiences with virtual care during a historical period that reshaped the delivery of primary care services.⁴⁰ The findings converged on seven key themes: enhancing access, importance of patient-provider relationships, active communication and attunement, assuring privacy and confidentiality, shorter appointments, asynchronous technologies being underutilised and strengthening the future of virtual care.

Our study demonstrates that virtual care has enhanced healthcare access for patients. Further, findings confirm that previous patient-provider relationship, active communication and attunement, and assurances about privacy and confidentiality all serve as factors for improving care. It also found that there are two factors that negatively impact the virtual care experience, and these include appointments in virtual care being shorter than in-person care and the limited use of asynchronous technologies coordinated with virtual visits. Addressing the factors that negatively impact virtual care experiences, providing patients with a choice in the modality of their appointment, and providing virtual care guidelines and education to physicians were identified as enhancements that can improve the patient experience with virtual care. It is important that policy and planning for future health decisions is informed by research that incorporates the perspectives and needs of the patients they aim to serve.⁴¹ By engaging patient perspectives in health system research, knowledge about what works best and what requires improvement can be realised and then addressed by policy makers to ensure the sustainability of virtual care.⁴¹

Access

Patient-centred access to healthcare can be defined as the opportunity to identify healthcare needs, seek out, reach, obtain or use healthcare services and to have the need for services fulfilled.⁴² Findings in our study demonstrated that virtual care made primary care more approachable as it provided patients with a convenient and comfortable way to access care. Participants noted that if virtual care was not an option, they may not have ever reached out for care. The pandemic was the catalyst for the exponential increase in the use of virtual care services offered by healthcare providers.⁴ In doing so, it made virtual care an available option for patients who may not have been able to access it previously.^{16 21 43 44} Our study found that the increased availability of virtual care led to an increased ability for patients to reach healthcare as it provided patients the flexibility to integrate healthcare appointments within their daily schedules when balancing challenges related to mental health concerns, chronic pain, disability, personal mobility and transportation. As virtual appointments were of no additional cost to the patient, virtual care became preferable for many participants. Virtual care saved patients from spending money on transportation and financial hardships from missing work. For some patients, virtual care appointments were also more efficient and thus saved them time itself. However, these benefits were only realised when the problems the patient was experiencing could be addressed through their virtual appointment. Despite these access benefits, a few participants did not want virtual care at all. Overall, most patients in our study noted that virtual care was an appropriate care modality for them as they found it to be approachable, acceptable, available and affordable.

Virtual care also facilitated the increased involvement of a patient’s family and friends in their care appointments via telephone and/or video. Participants were enthusiastic about the ease with which caregivers and family members could be involved in their care. Involvement of family members in the care of the patient can help family members better understand how to support the patient.⁴⁵ Family members can also serve as a valuable source of health information for the primary care provider.⁴⁶ The involvement of family has been shown to help improve health outcomes for a patient and improve adherence to medication and treatment plans.1647,52 For patients with mental illness, it can reduce the number of relapses, increase compliance to treatment and medication plans and decrease hospital admissions.53,55 Virtual care improves how accessible and accommodating healthcare is and thus increases a patient’s likelihood of engaging with the healthcare system. One limiting factor to virtual care, however, is whether a patient has access to technology that can support their virtual care appointment. While participants in this study did not report having technological issues, other studies have looked at access to telehealth in low-income patients and in areas with structural disparities to digital access.^{21 43 56 57}

Patient-centredness

The likelihood that a patient has a positive experience with virtual care may be related to the strength of the patient-physician relationship. Participants in our study who had a pre-existing, positive relationship with their family physician described positive experiences with virtual care. However, for participants who were experiencing virtual care with a new physician, the chance of a positive experience was stifled by the reduction in opportunities to build a new relational connection. Trust is a central feature of the patient-provider relationship.^{58 59} Patients want to know they can trust their care provider; however, this trust can be difficult to establish when in-person contact is missing. Over virtual modalities, particularly telephone, there is an absence of expressive touch, eye contact and reflective body language which are key actions that facilitate connection and trust between a primary care provider and their patient.^{18 60} A patient’s first visit with a new primary care provider is critical in shaping the attitudes and behaviours that influence the quality of the foundational therapeutic relationship.⁶¹ A first care experience with a new physician, nurse practitioner or other primary care provider can influence their future behaviour of returning for a second visit or following the care plan they were provided.⁶¹ When trust and rapport are built, patients have better care experiences and are more involved in decisions about their care.⁶¹

Patients in our study who had pre-existing positive relationships with their family physician shared concerns that the long-term use of only virtual care may erode the strength of that relationship. Poor patient-physician relationships are a concern because they can decrease the sense of comfort patients feel with their doctor, weaken the quality of care they receive from their doctor, negatively impact patient health outcomes and can cause patients to become hesitant in seeking out future care.¹⁸ Over time, virtual care should be complemented by in-person care to ensure that patients can build and continue to maintain their connection with their physician. An interesting finding from our study was that patients expressed deep appreciation for unscheduled telephone calls from their family physician as they found it to be a demonstration of their physician’s care and concern. As such, while virtual care can have the potential to erode patient-physician relationships, it also can improve these relationships. It may be of value, however, for future studies to discern the difference between unscheduled virtual interactions compared with scheduled appointments.

Our study found that active communication and attunement are factors that impact the patient-provider relationship and a patient’s virtual care experience. Effective communication between a primary care provider and their patient is a central component in building a therapeutic relationship and a positive experience.⁶² This was exhibited in our study as participants noted that when their family physician or other primary care provider had strong interpersonal skills, active communication and high attunement, they had a better experience during their appointment. These skills are especially important during telephone appointments as there is an overt reliance on communication skills due to the absence of visual assessment. Some participants noted that during their virtual care appointment, their family physician appeared even more attuned to what they were saying in comparison to in-person appointments, and this also led to greater experiences with virtual care. Our findings are in line with previous research that demonstrated a physician’s friendliness, warmth and emotional support are associated with patient satisfaction.⁵⁸ The onus of effective communication does not only fall with the primary care provider. Patients who were better prepared for their virtual appointments found that it helped them facilitate a more effective care appointment. This is because patients were able to note the specific questions they wanted answers to and were able to communicate their needs more effectively within the time constraints of their appointment.

A concerning finding from our study was that some patients reported that their virtual appointments were shorter and more rushed than in-person appointments. Even more concerning is that our study is not alone in this finding.^{18 28 29} Patients in our study indicated that their appointments were limited to the problem they were facing and there was no opportunity to openly discuss other issues. This is a concern because it illustrates that during virtual care appointments, family physicians and other members of the patient’s primary care team may be prioritising problem-focused care rather than whole-person care. While problem-focused care allows primary care providers to address the key ailment of the patient, it didn’t seem to facilitate conditions for a comprehensive assessment of the patient’s health beyond the initial problem. Shorter and more rushed appointments may have contributed to reduced satisfaction among participants in our study. Studies demonstrate that shorter appointments are associated with a higher likelihood of inappropriate prescribing,⁶¹ reduced satisfaction with the quality of care received⁶² and reduced quality of care.63,65 Shorter appointments, however, may not be an inferior care option for all patients.⁶⁶

Continuity and coordination

Continuity and coordination of care are some of the core hallmarks of primary care⁶⁷ and can lead to better health outcomes and higher patient satisfaction rates.⁶⁸ Continuity of care involves a practitioner’s ability to provide quality healthcare over time and across healthcare providers,⁶⁹ while coordinated care involves the coordination and sharing of information about a patient’s care plan with two or more care providers.⁷⁰ One possible way to enhance continuity and coordination of care is to improve the availability of asynchronous virtual care. Asynchronous virtual care enhances continuity and coordination because it allows patients to communicate with their family physicians and primary care team outside of scheduled appointment times and allows for digital documentation of care concerns and care plans.⁷¹ Asynchronous care serves as a tool for primary care providers as it allows them to engage with patients without having them present in real time. Asynchronous care allows for patients to have advanced access to care, and advanced access has been identified by physicians as something that ensures care continuity.^{67 72 73} Asynchronous communication has also been shown to improve the management of chronic disease.⁷¹

Our study found that participants are reporting a need for greater mechanisms to asynchronously access and share information with their care providers before and/or after their telephone and/or video appointments. The information participants would like to share includes photographs of problem areas, healthcare documents and topics associated with their care needs. Further, they would appreciate asynchronous options that allow them to access documents from their physician without having to go into the physician’s office. Participants in our study who had access to asynchronous methods of information sharing reported positive experiences with its use. A study examining primary care physician perspectives on the clinical utility of virtual visits revealed that most primary care physicians prefer asynchronous messaging because it offers them convenience and flexibility.⁷⁴ These physicians also agreed that virtual care can improve access and continuity of care for patients who experience logistical barriers to accessing services or for patients with chronic conditions.⁷⁴ Results of a rapid review of the literature found that asynchronous care can optimise tasks that do not require the presence of patients, can improve the overall quality of care provided, assist in the management of patients and improve the efficiency of the health system.⁷⁵ Based on our study findings, integrating asynchronous virtual care will benefit patients’ experiences as a complement to telephone and video appointments. Asynchronous virtual care is a beneficial tool for both patients and physicians and should be broadened across primary health services.

Future of virtual care

Participants in our study appreciated the ability to access care virtually and desired that this option remains open to them. Further, participants in this study expressed that having a combination of both in-person and virtual appointments is optimal for the care system moving forward. Virtual care has allowed participants to access care at more flexible hours, have better care coordination and have better access overall. It has provided patients with a new way of experiencing care, and these experiences have been positive for most of the participants in this study. Virtual care falls short, however, when physical assessments are necessary and, as such, it is complementary to in-person care.

Virtual care is a complement and not a replacement to in-person care. Each modality offers its own benefits and consequences. Further, within virtual care, there is a choice between telephone and video appointments, and these also have their own benefits and consequences. The findings in our study showed that the preference of the provider often determined the type of technology used during a virtual appointment. In our study, telephone appointments served as the main modality rather than video, which was consistent with other studies on virtual care in Canada.³ Video was only used if the patient specifically requested it or when the provider wanted to do a visual assessment. Participants in our study identified that when they have the choice of how their appointment takes place, they have a more positive experience. By offering the patient a choice of how they would like to have their appointment, you provide them with their own autonomy and, in doing so, reduce the power dynamic experienced between a primary care provider and patient.⁷⁶ However, while it is important that patients are offered choice and feel in control of their care, it is not clear as to whether all patients can make the “right” decision on the type of appointment that best suits their needs for care.⁷⁷ Although medical office assistants are routinely interfacing with patients and assisting with appointment bookings, training medical office assistants in the process of choosing appropriate modalities for care is an overlooked area of primary care restructuring.⁷⁸

What remains unknown, however, is how patient experiences with virtual care vary across different types of primary care providers and services. Within our study, 53% of the sample identified as receiving primary care from an interprofessional team model, and just over 40% of the sample had a virtual visit with a non-physician provider. A better understanding of patients’ experiences with virtual care within interprofessional team-based models of primary care would be useful to determine how best to maximise access and collaboration to a range of service providers as interprofessional team-based models of care expand.⁷⁹ As the primary healthcare system continues to evolve, understanding patients’ experiences and preferences is essential to guide decision makers and leaders to determine how best to integrate and offer virtual care options.

Study limitations

There were several limitations present in this study. First, the interviews for this study were conducted in the first half of 2021, when the pandemic was in its most heightened state. As such, the experiences described are reflective of a time that followed an exponential boom in virtual services and do not reflect how virtual care has evolved since then. Second, this study focused on the patient experience with virtual care but did not include the perspectives of care providers who serve an essential role in the care experience. Third, as purposive sampling was used to recruit participants, the sample may not be representative of the broader population. While there is emerging evidence of virtual methods working well for qualitative data collection,³⁵ there is potential that conducting data collection via telephone and video may not have worked well for some patients with low digital literacy. Lastly, our study focused on the province of Ontario, Canada, so findings may not be transferrable to all primary care settings.

Conclusion

Virtual care offers a promising modality for patients to experience care. Moving forward, primary care practices should expand asynchronous virtual care options, address the length of virtual care appointments and offer patients greater choice in the modality of their care appointments.

Data availability statement

Data are available upon reasonable request.