Table 2.

Summary of emergent qualitative themes describing factors that in-person patients consider when scheduling future ambulatory neurology visits (n = 699)

Meta-theme (% of total codes)	Sub-theme (% of meta-theme)	Patient experience (% of sub-theme)	Representative patient quotes
Pros of Visit Type (31%)	Convenience (39%)	Elimination of commute time, associated gas and parking costs (71%)	“We live almost 4 h away, so we would like to have a telehealth appointment in the future.”
		Convenience for patients with limited mobility (9%)	“Virtual is much better [than in-person]. We do not have to go all the way there. Especially with my father—he has a movement disorder. So with his wheelchair, it [telemedicine] is just more convenient.”
		Convenience for full-time employees, students, or mothers (5%)	“Yes, I’d prefer telehealth because it is hard for him [the patient] to get off work.”
		Convenience due to elimination of need for access to a car or other modes of transportation (14%)	“I would prefer telehealth because I do not have transportation.”
		Convenience due to reduced or absent wait time at the physician office (0%)	“We always have to wait around 45 min to see the doctor when we go in-person.”
	Safety (6%)	Telemedicine is a safer option due to Coronavirus or other concerns (100%)	“For this one [visit], I could have done telehealth, and it probably would have been better. Just with COVID, it’s not completely over, so I’m not 100% comfortable going to the doctor’s office more than I have to.” “With MS, I stay in the bubble, trying to avoid as much contact as possible.”
	Humanistic Qualities (15%)	Telemedicine is family-centered by permitting multiple family members to be present at a visit (0%)	–
		In-person visits are more personable (100%)	“I would prefer to come in to see the doctor, because I just like to see the doctor face-to-face.”
	Quality of Medical Care (40%)	In-person visits provide improved communication (55%)	“I do not care for telehealth because sometimes you do not get your point across. It’s harder to communicate and feel on the same page.” “Sometimes, the doctors do not say exactly what they’re thinking, but if I’m there and I see something different, I will ask a question. On the telephone, I do not feel as comfortable asking questions.”
		In-person visits provide improved quality of care (41%)	“How can they tell anything over a video?” “I think there are things that can get missed when you do a telehealth visit.”
		In-person visits are more thorough due to a longer duration of visit (4%)	“I feel like I am heard more when it is in-person. The phone appointments seem too quick.”
Barriers to Telemedicine (9%)	Accessibility (21%)	Need for assistance with technology (47%)	“I would consider telehealth only if someone could teach me how to do it.”
		Lack of access to a telemedicine device (27%)	“I do not have a computer.”
		Insurance does not cover telemedicine visits (27%)	“It depends on how insurance pays it.” “It would depend on whether it costs the same.”
	System Limitations (14%)	Self-reported symptom limitations (30%)	“At in-person visits, you’re there looking at the person and they're looking at you. It’s not just verbal descriptions or describing things.”
		Technology system difficulty such as WiFi/internet connection, audio/video quality issues (70%)	“I prefer telephone over video only because I live in a rural area, and the virtual video conference freezes.”
	User Limitations (65%)	Difficult for children (35%)	“When the patient is older, perhaps 3 years of age, then I will consider a telehealth visit.” “I prefer in-person, especially if it’s dealing with my son, because it helps when a doctor can literally lay eyes on him and physically see him. There’s less distraction.”
		Lack of familiarity (39%)	“I do prefer in-person for custom or tradition. I am not comfortable yet with virtual.” “I would never prefer telehealth. I am old school. I’m sorry.”
		Communication difficulties due to hearing impairment (7%)	“I have two kids, and telehealth calls can be loud in my house.” “I have to help her [the patient] hear with video visits.”
		User technology difficulty (20%)	“I would not want a Zoom meeting. I’m 62. I’m not really in the mood to deal too much with technology.”
Situational Context (45%)	Stable Condition (21%)	Telemedicine is best for follow-up visits (57%)	“I would consider it [telehealth] if it was a follow up appointment.”
		Telemedicine is best for medication management (9%)	“I would maybe consider telehealth to discuss medications.”
		Telemedicine is best for non-emergent visits (3%)	“I would not want to do virtual visits for emergencies. Maybe for a rash.”
		Telemedicine is best for annual visits (31%)	“Moving forward, I would prefer to come in-person because I only see him [the physician] once a year. If it was something where I saw him more frequently, I would consider them [telehealth].”
	Severe or Undiagnosed Condition (29%)	In-person visits are preferred when symptoms are worsening (38%)	“If he [the patient] were doing well, I might want telehealth.” “I felt that since he [the patient] was having seizures, he needed a physical assessment.”
		In-person visits are preferred for severe or undiagnosed conditions (29%)	“I did not know at the time that I had a serious brain issue. We’re not talking about a hang nail—it’s serious enough that I wanted the doctor to be ‘in it to win it.’ I would not have chosen it [telehealth] given the severity.” “If a patient needs to have a medical work-up, that [a virtual visit] just seems reckless.”
		In-person visits are preferred for post-operative visits (3%)	“It was a follow-up after a surgery, so this is probably better in-person.”
		Telemedicine is best for emergent situations (1%)	“At that particular time, I was having an emergency. I live over an hour and a half away, so that’s why I preferred a virtual visit. I needed to speak to someone right away.”
		In-person visits are preferred for initial visits with a new provider (30%)	“I think the first visit was important in-person, but neurology is one department where we can do virtual visits. The first visit, there is so much anxiety, so it's probably better in-person. But for the second, third, and subsequent visits—we won’t mind having it virtual.”
	In-person Service Requirement (50%)	Telemedicine is best when no in-person services such as labs or imaging are required (25%)	“If she did not need any adjustments on her medical device, then I would consider a telehealth appointment.”
		In-person visits are preferred when in-person services are required (13%)	“If it’s something where they want blood work or vitals, then we want to be there in-person.”
		In-person visits are preferred when a physical exam is required (46%)	“We do not mind telephone visits, but if the patient needs to be evaluated for a physical need, we would want to come in-person.” “With neurology, in-person is best. They need to see how I’m walking and test my reflexes. It’s very hands-on.”
		In-person visits are preferred for botox visits (16%)	“I would not prefer telehealth. I needed a botox injection.”
Inherent Beliefs (9%)	Equivalence of Telemedicine and In-person (25%)	A telemedicine physical neurological exam is equivalent to an in-person exam (11%)	“I had to turn the phone around so [the physician] could watch him walk.”
		Telemedicine permits equivalent communication to in-person visits (11%)	“Many times, you just have questions, and I think those can be answered without an in-person visit.”
		Telemedicine provides an equivalent quality of care to in-person visits (32%)	“As long as they get the same results, telehealth is okay with me. We did one last year, and it was fine.”
		In-person and telemedicine visits are equally convenient due to close proximity to the clinic (16%)	“I was already in the area, so it made sense to get it out of the way while I was there in-person.” “I would prefer in-person because the clinic is literally 5 min from the house.”
		In-person and telemedicine visits are equally safe due to COVID-19 protocols and vaccinations (32%)	“I am vaccinated, so I am fine with in-person.”
	Indifference (54%)	The utility of telemedicine depends on specific needs for the visit (54%)	“For some things, coming in is better.”
		Telemedicine is a suitable alternative to in-person visits during COVID-19 (15%)	“I have done telehealth at the beginning of COVID, and it was fine.”
		Patients have no preference for telemedicine or in-person visits (32%)	“It honestly does not matter to me.”
	Superiority of In-person Visits (21%)	Telemedicine should only be utilized as a last resort when in-person visits are not available (100%)	“If an in-person visit was not an option, then yes, I would have done a telehealth appointment.” “I would consider a telehealth appointment if I really had to.”
Extrinsic Variables (7%)	Awareness (79%)	Patients were unaware that telemedicine visits were an option (100%)	“I did not know it was an option.”
	Alternate Decision-maker (17%)	Family member/caregiver selected the visit type for the patient (11%)	“My wife had set it up.”
		Physician or administrative secretary selected the visit type for the patient (89%)	“I just do what the doctor tells me to.”
	Availability (4%)	Telemedicine is selected when it is the first available appointment (100%)	“If it [telehealth] could get me seen sooner, that would be ok.”