TABLE 2.

Representative Quotes of Themes

MS telemedicine technology
Increased access and convenience	1. Not only was I televisiting with [my patient], she was able to link me into her parents and so I have a 3-way televisit. It’s like I had all of them in the room. I’m looking at all their faces. (nurse practitioner, 26 years in practice) 2. I truly believe it’s the difference between treatment and no treatment for those folks [who] have a tough time getting to the facility, affording the bus, being able to park. Oftentimes, the folks that don’t have access are probably the people that need it the most…especially for patients in mental health. (psychologist, 5 years in practice)
Technical challenges	3. I was like, “OK. How are we going to do this?” I could probably assess your cranial nerves, depending, but some people’s cameras are crappy, or the connection is crappy and it’s all pixelated and you can’t see. (nurse practitioner, 16 years in practice) 4. Sometimes people just can’t sign on for whatever. There’s a glitch or you get cut off. And then I’ll just hang up and call them and finish the visit on the phone because you can get very stressed. [Patients] want to do a good job on this, and if they’re not comfortable with technology, it makes them very anxious. And that’s not the point of the visit. (nurse practitioner, 27 years in practice)
MS telemedicine clinical encounters
Confidence in telemedicine varies	5. A thing I miss with seeing [my neurologist] in person for the follow-ups right now is just the evaluations. I do have drop foot with MS; he can’t really gauge me walking too well. I mean, he can a little bit, but not fully. And then grip strength and my balance stuff. He could kind of assess it because I do stand up, and he has me close my eyes. But I don’t know if he could fully assess that. (woman, 58 years old, EDSS score 1.0–5.0) 6. For patients that you know well, I think the [telemedicine] exam is sufficient. [It shouldn’t] be the only way to see patients, but I think it is an extremely effective way in between face-to-face visits. (neurologist, 20 years in practice) 7. Doctors tend to be stuck in and liking and continuing to do that which they were taught to do at the beginning, back in their residency for instance. And so we do have a degree of fluency that’s required for providers to get them comfortable with [telemedicine]. (policy expert–advocacy organizational representative–telemedicine) 8. We can do a lot. I think it’s underrated, the amount that PTs can do without hands-on. (physical therapist, 6 years in practice)
Virtual “house call” benefits	9. I have this [patient] that I see with progressive MS. Although, she’s still ambulatory…she’s very disabled. She also has some cognitive difficulties. So, the best thing was when I was able to do a televisit for her. I was in her home. And, in fact, she had no barriers. She walked that telephone around everywhere. And I saw every ounce of her home.…When they come in our environment, it’s very sterile. It’s us. (nurse practitioner, 26 years in practice) 10. Normally with my doctor’s visits, my wife is there. She’s my caregiver.…I’ll tell her, “Now, be sure to remind me to ask this or that.” [But after my televisit,] I came away with, “Oh, I wish she’d been there. I forgot to ask this and this.…” Kind of an interesting dynamic, because [my wife] doesn’t need to be there physically to drive me or help me in and out of chairs. (man, 51 years old, EDSS score ≥6.0) 11. I feel like I’m able to establish rapport almost faster via telehealth. I think their ability to see my face, to see their face, it really keeps it present for them. (neuropsychologist, 2 years in practice) 12. I think that’s a brutal way to get delivered this message.... If you just pop up on a screen and say, “Hey, you have MS,” and then you just close the window and just close the laptop. What happens on the other side of that with the person that is hearing that information? (man, 37 years old, EDSS score 1.0–5.0)
Financial reimbursement and infrastructure for MS telemedicine
Reimbursement parity	13. As oftentimes happens when wars, pandemics, disasters occur, some parts of the economy and some parts of our world sort of shrink and die, but other parts take off and expand in a very meaningful way. And I think telemedicine is one of those things.…The fact that the red tape was removed, which I credit the federal [and] state governments that kind of followed suit and very quickly removed all these different regulatory…and insurance-related reimbursement barriers that prevented people from effectively using telehealth previously. I really hope that that stays. (neurologist, 15 years in practice)
Hope and fear as infrastructure and business models begin to shift	14. I don’t think the payers saw the [dollar-]value of remote care. They saw, “Well gosh, the health care system does less work and expects the same amount of reimbursement.” Because when you do a telehealth visit, there’s no nurse checking in the patient. There’s no lab tech coming around afterwards to draw blood or anything. It’s just a one-to-one encounter. And to some extent that’s true.…There’s less overhead for a telehealth visit than there is for a face-to-face visit. (policy expert—information technologist)
Familiar structure of office visit	15. I felt like I got ripped off here. How do you know my heart’s OK? How do you know my lungs are OK? (woman, 57 years old, EDSS score 1.0–5.0) 16. The whole thing with telemedicine that I don’t like is that a nurse doesn’t “room” you. So, you go direct to the doctor. You don’t get another person saying what your complaint is, explanation, just talking with you, getting vitals, which I think are a big thing. (woman, 52 years old, EDSS score ≥6.0) 17. You don’t get a chance to finish the appointment. It’s like “OK, I got to go.” “OK.” But then you don’t talk to anybody else. You hang up....so I just left the appointment: “What’s my next step?”…It’s kind of like leaving me out in left field so, I do feel alone in that respect. When they finish, they should put you out to the front desk. (woman, 52 years old, EDSS score 1.0–5.0)
Telemedicine intentionality	18. I’ve had patients pick up the phone when they’re driving, which is kind of terrifying, or in the middle of the woods. I think that you do want to make sure that folks understand that this is formal treatment, and, even though you’re not in the room, it is still a dedicated hour. (psychologist, 5 years in practice) 19. It’s just important for doctors to take these telehealth meetings as serious…the same intentionality I guess that they use [in person, so] that you don’t feel like they’re just phoning it in, to use a cliché. That you really feel that they’re there at that moment, even though they may be in their house, study, or whatever, that they really use the same decorum and professionality that they would use if you were in-person. (man, 51 years old, EDSS score ≥6.0) 20. [T]he patient is in the waiting room and you can use that opportunity to deliver patient education messages. Let them browse articles. And then a nurse or a medical assistant or somebody could come into the waiting room and interact with the patient. And then the doctor could come in after that and interact with the patient and make it more of a ritualized experience versus what Zoom is like now which is you sit staring at a blank screen until the provider shows up. So we’re trying to recreate in Epic that waiting room experience and make it so that, that can engage both the health information…I guess we have to find some 15-year-old magazines to throw around [laughs] to make it the true waiting room experience. (policy expert—information technologist)

EDSS, Expanded Disability Status Scale; MS, multiple sclerosis; PT, physical therapy.