| Outer setting |
“The biggest barrier [was ordering and receiving] labs [from other facilities] and putting them into the patient's chart for the doctor to review before the visit… There have been a couple instances where we have had to delay telemedicine visits for our patients because the doctor doesn't have the results yet” (staff). “Well, institutionally, if it's not paid for, they won't use it…They haven't embraced it before COVID. I think COVID just pushed it into the mainstream. So that's a huge barrier in theory. And I hope [insurances] will recognize the benefit” (provider).
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| Inner setting |
“The other piece that we're still trying to create a better workflow for is the rooming process… [Providers] don't have the clinical support to be able to have somebody touch base with the patient prior to them joining the video, or the telephone call if that's the case. That piece is something that we're still trying to make more efficient, is having that virtual rooming where the MA is able to start the visit, collect that information, get it entered into the encounter for the provider” (staff). “The main workflow in the clinic is we get our schedule, and we looked at the schedule, and I go through the patients and look at the diagnosis. And then I decide which patient is appropriate for telehealth, and which patient is not. And it is the secretaries who called the patient” (provider).
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| Intervention characteristics |
“I think the lack of a real physical examination is a real rapport problem. There's something quite unique about the physician doing a physical exam that communicates a lot of unspoken things to the patient… [It is] hard to describe” (provider). “[My mix of phone vs video is three fourths phone and one fourth video]. The videos can be a little tedious and for the video, the patient has an appointment for which they're sitting in front of their computer. So, if I'm running 30-minutes late, they're stuck in front of their computer. Where the phone…they could more or less live their life and go about their day and I'll call them on their cell phone. And so, from my perspective [it] is much more convenient” (provider). “I do think over the telephone I miss the non-verbal cues. If I'm in the exam room or virtually I'm with the patient and a family member and I say something and they get this look on their face and I can say so, you look like you're maybe not comfortable with that or your wife just shook her head in the opposite direction of you. There's more non-verbal cues that then tell me to sort of pursue that a little further, especially things like depression. Sometimes I can tell that more. They may not say they're depressed, but I can tell they're not really maintaining eye contact well or they're kind of a flat affect. You don't get that over the telephone” (provider).
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| Characteristics of individuals |
“For our patients, who are either frail, rural, or both, when there's travel issues, or even they don't have a lot of gas money, like being able to say, “Listen, it's okay. We'll do a tele-visit,” is awesome” (provider). “We have an older, sicker population who may be less computer savvy, may have less access to high-speed Internet, and have a reluctance to incorporate the technology into their lives” (provider).
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| Implementation processes |
“[Providers are using telemedicine] for long-term follow-ups, for discussion visits, for chemo teachings, for results discussion visits, for patients who live far away and don't want to come in. And for patient side, I see it as for the exact same reason, for patients who say, “I live two hours away. Can this be a phone visit?” And we say, “No problem. Happy to help” (staff). “[The providers] see a lot of patients on treatment, so they see them, when they're getting their treatment in the infusion suite… I don't know how many of them have done [telemedicine] in between. I'm just starting to see because we share a lot of patients where they'll do an in between checkup visit by video. I'm seeing a little more of that where they're not actually getting their chemo, but I think the majority of their patients are actually getting treatment the same day they see the provider” (provider leader).
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