Implementing Team-Based Telemedicine Workflows in Safety-Net Primary Care

ABSTRACT

Objectives: Challenges in implementing telemedicine disproportionately affect patients served in safety-net settings. Few studies have elucidated pragmatic, team-based strategies for successful telemedicine implementation in primary care, especially with a safety-net population.

Study Design: We conducted in-depth, semistructured qualitative interviews with primary care clinicians and staff in a large urban safety-net health care system on the facilitators, challenges, and impact of implementing team workflows for synchronous telemedicine video and audio-only visits.

Methods: Interviews were analyzed using modified grounded theory with multistage coding. Common themes were identified and reviewed to describe within-group and between-group variations. We used the Practical, Robust Implementation Sustainability Model framework to organize the final themes with an implementation science lens.

Results: Four themes emerged from 11 interviews: (1) having a dedicated individual preparing patients for video visits is a prerequisite for the successful introduction of video visits to patients with limited digital literacy; (2) health care maintenance during video and audio-only visits benefits from standardized workflows and communication; (3) the increased flexibility and accessibility of telemedicine visits were perceived benefits to patient care, despite barriers for subsets of patients; and (4) telemedicine visits generally have a positive impact on work experience for clinicians and staff due to increased efficiency, despite audio-only visits feeling less engaging.

Conclusions: Understanding how to strategically use team-based workflows to expand video visit access while ensuring care quality of all telemedicine visits will allow primary care practices to maximize telemedicine’s benefits to patients in the safety-net setting.

Am J Manag Care. 2024;30(Spec Issue No. 6):SP437-SP444. https://doi.org/10.37765/ajmc.2024.89550

Takeaway Points

Clinicians and staff in safety-net primary care clinics recognized that team-based workflows can help expand video visit access and improve health care maintenance in telemedicine visits.

• Dedicated staff providing navigation support for video visits are necessary for safety-net populations to access these visits.
• Workflows to consistently and equitably offer video visit options to patients are also needed.
• Standardized team-based workflows and communication facilitate health care maintenance in telemedicine visits.
• Ensuring high-quality preventive and chronic care during both phone and video visits will be important as patients continue to face barriers to video visit access.

The COVID-19 pandemic spurred health care systems to rapidly transform telemedicine from an uncommon innovation in most outpatient settings to a fundamental modality of care^.1-3 Prior to reimbursement changes during the pandemic, using telemedicine to deliver synchronous care via video and audio visits was especially rare among safety-net clinics providing primary care to low-resource populations.^4-6 The challenges of telemedicine implementation disproportionately affect safety-net institutions and their patients. Patients who identify as part of racial/ethnic minority groups, have limited English proficiency, or have lower socioeconomic status face increased barriers to accessing telemedicine, including lower device, internet, and data access and limitations in digital literacy.^7-15 The “digital divide” between those with and without resources to access technology-based health innovations affects many of the same populations already affected by health inequities.^16-19 Thus, the medical community has highlighted the importance of addressing equity in telemedicine access to help reduce existing disparities in health care delivery and outcomes, rather than exacerbate them.^20,21

With primary care’s foundational role in improving population health and narrowing health disparities,^22,23 understanding telemedicine implementation in safety-net primary care settings is particularly relevant.²⁴ Studies typically depict patient or clinician perspectives on general benefits and challenges of telemedicine or patterns of utilization,^7,25-37 but they have yet to detail specific workflow characteristics that support implementation and sustainability, especially within the context of primary care teams.

Team-based care adapts roles and workflows for the optimal contribution of nonphysician team members,³⁸ and there is a need to understand how best to incorporate primary care team members into telemedicine workflows. Although one study outlines examples of adapting team-based care to telemedicine,³⁹ it is based in a practice setting with resources for advanced team-based care. Given the resource constraints for practices serving a safety-net population with limited digital literacy, specific research is needed around how to operationalize team-based telemedicine in safety-net settings. Furthermore, prior studies have focused on clinicians or system leaders^26,29-32 despite the importance of staff perspectives in primary care teams.

To bridge these gaps and better elucidate pragmatic, team-based strategies for implementation of video and audio visits in safety-net primary care, we assessed clinician and staff perspectives on the facilitators, challenges, and impact of implementing team-based telemedicine workflows.

METHODS

Setting/Population

This study was conducted in a large urban clinic network serving an ethnically diverse, publicly insured patient population, with a large proportion of patients primarily speaking non-English languages. In this network of 14 primary care clinics, telemedicine visits (defined as synchronous video or phone visits with a clinician) were not routinely offered prior to the COVID-19 pandemic.

The 3 sites serving as the study setting included 2 community-based family medicine clinics and 1 internal medicine residency clinic. These sites were selected due to their piloting of 2 team-based telemedicine workflows. One workflow supported video visits through a “support pool” to which clinicians and staff could refer patients needing video visit orientation. The support pool consisted of volunteers who called patients ahead of visits to guide them through the process of starting a video visit. The other workflow incorporated health care maintenance (preventive and chronic care tasks) into video and audio-only telemedicine visits by using standardized “virtual rooming,” where medical assistants called patients to coordinate health care maintenance tasks before telemedicine visits. Workflow details are provided in eAppendices A and B (eAppendices available at ajmc.com).

During the study period, audio-only visits represented 31.5% of all primary care visits in the network and 35.6% of visits at the 3 pilot sites. Video visit prevalence was 0.4% (796 visits) in the network and 0.8% (196 visits) in the pilot sites.

Study Design

We performed in-depth qualitative interviews with clinicians and staff at the 3 clinics. Participants were recruited using a purposive sampling strategy, in which clinics identified clinicians, medical assistants, and managers with firsthand experience implementing the telemedicine workflows. Researchers invited eligible participants via email to take part in a Zoom interview, and both clinician and staff interviewees were included from each site. The interview instrument (eAppendix C) was designed using stakeholder input. Verbal consent was obtained at the time of the interview.

One-on-one semistructured interviews were conducted between October 2021 and April 2022, until the research team observed no new concepts arising from interviews, suggesting thematic saturation.⁴⁰ Interviews were audio recorded, deidentified, and transcribed verbatim using autotranscription followed by review by the interviewer for accuracy. The study protocol was approved by the University of California, San Francisco Institutional Review Board (study # 11-08048).

Analysis

Coding and thematic development were conducted in an iterative process. Interviews were dual-coded by the interviewer and a trained research associate using modified grounded theory with multistage coding.⁴¹ The analysis team reviewed a sample of 3 transcripts to identify recurrent ideas and organize them into a codebook, which was piloted and refined with additional transcripts. To calibrate between coders, team members independently coded a subset of 4 transcripts, then met to identify and resolve discrepancies. They then used the codebook to code each transcript and met weekly to review and discuss coding decisions until a consensus was reached. An additional transcript was dual-coded and reconciled later in the coding process to avoid drift in intercoder consistency. Dual-coded interviews were entered into Atlas.ti version 9.1.7.0 (Atlas.ti Scientific Software Development, GmbH). Common themes were identified and reviewed to describe within-group and between-group variations. Final themes were selected based on prevalence among interviewees and relevance for implementing telemedicine workflows.

To organize the final themes with an implementation science lens, we used the Practical, Robust Implementation Sustainability Model (PRISM) framework, which describes multilevel contextual factors relevant to program implementation.^42-44 The PRISM framework evaluates how health care interventions interact with the external environment, intervention design, implementation and sustainability infrastructure, and the multilevel recipients of an intervention.^42-44

RESULTS

Of 19 individuals across the 3 clinics invited to take part in this study, 11 participated, for a response rate of 57.9%. These included 4 primary care clinicians, 5 medical assistants, 1 nursing manager, and 1 practice manager. At least 1 clinician and 1 medical assistant from each clinic were interviewed. Participants had worked at their sites for a mean of 5 years, ranging from 7 months to 10 years.

Four themes emerged, corresponding to the impact of telemedicine workflow implementation on video visit uptake, health care maintenance, patient care, and clinician/staff experience, with the latter 3 themes pertinent to both audio and video visits. Within the PRISM framework, the first 2 themes corresponded to the implementation and sustainability infrastructure domain, whereas the latter 2 mapped to the patient and organizational perspectives and characteristics (Figure^42-44). Representative quotes are summarized in the Table [part A, part B, and part C].^42-44 Nonclinicians are referred to as “staff” for simplicity.

Theme 1: Having a Dedicated Individual Preparing Patients for Video Visits Is a Prerequisite for the Successful Introduction of Video Visits to Patients With Limited Digital Literacy

Seven of 11 interviewees reported that having a dedicated staff role to orient patients with limited digital literacy to using video visits was essential. They described that the amount of time needed to help patients through the process became unfeasible for current staff to balance with existing duties.

Five of 11 interviewees described the video visit support pool as a helpful resource for supporting patients to use video visits. Two staff noted this was limited by whether the patients were contacted in time for their video visits. Five of 11 interviewees observed barriers at the upstream stage of offering video visits to patients.

Theme 2: Health Care Maintenance for Telemedicine Visits Benefited From Standardized Workflows and Communication for Medical Assistant Virtual Rooming

All interviewees from the community-based sites (3 clinicians and 4 staff) reported that the virtual rooming workflows improved health care maintenance quality for telemedicine visits. Four interviewees said that by using the workflows, the perceived difference between in-person and telemedicine preventive care was small or negligible. Among the community-based clinics, 2 clinicians and 2 staff members commented that having standardized workflows facilitated consistent completion of health care maintenance tasks for telemedicine visits.

In contrast, interviewees from the teaching clinic site reported more challenges with consistency of the workflows, with variability in how often preventive care was completed for telemedicine visits. Seven of 11 interviewees from all 3 clinics described medical assistant staffing shortages or turnover as a barrier to successfully implementing standardized preventive care workflows for telemedicine visits.

Seven of 11 interviewees reported logistical barriers to completing health care maintenance tasks during telemedicine visits compared with in-person visits. These included patients needing to be scheduled to return for in-person preventive care tasks (eg, vaccines or cervical cancer screening) and perceived decreased priority of virtual rooming workflows when medical assistants were busy with in-person patient tasks.

Theme 3: Increased Flexibility and Accessibility of Telemedicine Visits Were Perceived Benefits to Patient Care, Despite Barriers for Subsets of Patients

All 11 interviewees observed increased visit flexibility and accessibility as key patient care benefits of having telemedicine options, especially for younger patients, patients less able to take time off from work or caregiving responsibilities, and those with mobility difficulties. Many staff members and clinicians specifically noted the benefits of being able to switch from in-person to a telemedicine visit when last-minute circumstances otherwise would have led to a no-show or cancellation. However, 10 of 11 interviewees also noted patient subgroups with more barriers to telemedicine, including older patients and patients with low digital literacy.

Four of 11 interviewees also observed that telemedicine visits seemed to be more useful than in-person visits for care delivery in certain scenarios. For example, 2 of 4 clinicians described telemedicine as a good format for discussion of results with patients, when previously this might be done only at a patient’s proactive request, and a staff member described telemedicine as a good format for ordering durable medical equipment.

Three of 11 interviewees also identified the need to improve protocols to identify the most appropriate visit format. Two of 4 clinicians raised concerns about delays when an issue is attempted to be addressed over telemedicine but actually requires an in-person evaluation.

Theme 4: Telemedicine Visits Generally Have a Positive Impact on Work Experience for Clinicians and Staff Due to Increased Efficiency, Despite Audio-Only Visits Feeling Less Engaging

Ten of 11 interviewees described telemedicine visits as bringing more efficiency into the clinic schedule and flow. Four of 7 staff specifically described the flexible timing of telemedicine visits as helpful for their time management. Three of 4 clinicians reported that telemedicine visits had a positive impact on burnout or work exhaustion due to these benefits. The 3 clinicians from the community-based sites described the involvement of medical assistants in health care maintenance for telemedicine visits as helpful for reducing burnout.

Two of 4 clinicians and 2 of 7 staff also commented that phone visits had less sense of connection or relationship compared with in-person visits. The clinicians reported that this resulted in less joy in practice, but also that video visits could be more rewarding than audio-only visits.

DISCUSSION

We identified key facilitators and barriers with clinician and staff agreement around the strategic incorporation of 2 telemedicine workflows in busy, underresourced safety-net primary care clinics. Pertinent to the implementation and sustainability infrastructure domain of PRISM, we found that optimizing telemedicine in public delivery systems requires dedicated support staff to orient patients to video visits. This would require hiring additional staff or offloading other responsibilities from existing staff to create team-based capacity for telemedicine orientation. A few prior studies have called for devoting resources to providing digital navigators to overcome video visit barriers,^35,45-47 and this study provides supporting evidence for this need, especially in settings where limited digital literacy is more common among patients. After a critical threshold of patients receive video visit teaching and lower volumes of patients need ongoing teaching, digital navigation may be more easily integrated into existing staff roles sustainably. However in settings with large proportions of patients with limited digital literacy, a significant up-front investment in digital navigation will be necessary.

Our findings also suggest dedicated navigation support is necessary but insufficient without additional workflows to consistently offer video visit options to patients. There has been evidence of lower rates of offering video options to certain populations (eg, Hispanic, non–primary English speaking, and Medicaid/Medicare dually eligible patients) even after controlling for access to a smartphone/tablet and home internet.⁵ This is consistent with literature on disparities in offering other technological health innovations, such as patient portals.⁴⁸ Thus, further development and evaluation of workflows to ensure standardized offering of video visit options and support will be an important step in operationalizing video visits effectively and equitably.²⁰

Consistent use of team-based workflows was an important contributor to providing health care maintenance during video and audio visits. One study in a large integrated health system found that patients with telemedicine exposure had better rates of chronic disease and counseling-based preventive care metrics,⁴⁹ suggesting that these components of primary care can translate effectively to telemedicine formats. Additionally, this study showed that a team-based virtual rooming workflow can be successfully applied to health care maintenance in the safety-net setting. Interviewees from the community-based sites that reported higher consistency of these workflows noted that clear role expectations and opportunities for team communication facilitated successful implementation, which should be built into future telemedicine workflow initiatives. Clinicians from these sites also described that the health care maintenance workflows helped reduce exhaustion or burnout, further supporting the value of investment in team-based telemedicine workflows.

In the patient and organizational domains of PRISM, our findings aligned with those previously reported in non–safety-net settings,^28-30,33-36 with flexibility, accessibility, and efficiency being major benefits of telemedicine visits despite certain limitations and barriers. For safety-net populations in which patients commonly face increased structural barriers to accessing in-person health care, such as transportation issues or limited ability to take time off from work, the flexibility of telemedicine options may provide particularly important accessibility benefits. For example, the ability to convert in-person visits to telemedicine visits provided patients more flexibility for in-person visits that could have become no-shows. No-show rates of scheduled telemedicine visits themselves did not emerge strongly in our interviews but would be important to explore in future studies. Interviewee descriptions of using telemedicine effectively in certain situations and for efficient clinic flow support further development of best practices for strategically triaging telemedicine visit formats to best meet patients’ clinical and accessibility needs.

Limitations

Limitations of this study include that staff and clinician experiences were more representative of audio-only visits. Further perspectives obtained with scaled-up video visit volumes could offer additional insights into impacts of telemedicine on care delivery, for example, whether video visits would ameliorate the reduction in clinicians’ perceived rapport and engagement during audio-only visits. Another limitation is the small sample size, although our patient and organizational perspective findings corroborated those of prior studies, supporting our assessment of thematic saturation.

This work highlights the importance of designating and funding specific staff to provide telemedicine support for video visits as well as sufficient staffing to consistently implement health care maintenance workflows to improve quality of care in telemedicine visits. Equitably supporting patients to engage in video visits while simultaneously ensuring high-quality preventive and chronic care during both phone and video visits will be important as patients continue to face barriers to video visit access and decisions evolve around reimbursement for audio vs video visit types.^13,50 Further research should examine optimal workflows for consistently and equitably offering video visits to patients in safety-net settings. The noted difficulties with consistently implementing team-based workflows in the large teaching clinic compared with the community-based sites in this study also suggest that future work should give attention to the particular nuances of telemedicine implementation in more complex primary care settings, such as residency clinics.

CONCLUSIONS

Clinicians and staff in this study recognized the challenges but also the value and facilitators of providing telemedicine care to often marginalized populations. Continuing to understand how to strategically use team-based workflows to expand video visit access while ensuring care quality of all telemedicine visits will allow primary care practices to maximize telemedicine’s flexibility and benefits for patients in safety-net settings.

Author Affiliations: University of California, San Francisco (MK, RW-G, EK, AS, GS, DT), San Francisco, CA; University College Dublin (MM), Dublin, Ireland.

Source of Funding: This work was supported by the Tides Foundation, in collaboration with the Center for Care Innovations and California Health Care Foundation (TF2007-093073), and the University of California, San Francisco Population Health and Health Equity Scholars program.

Author Disclosures: Dr Khoong has a career development award grant from the National Institutes of Health on team-based home blood pressure monitoring, has a grant pending from the Agency for Healthcare Research and Quality focused on team-based home blood pressure monitoring, and has received honoraria for speaking at universities about telehealth inequities. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MK, RW-G, EK, AS, DT); acquisition of data (MK, DT); analysis and interpretation of data (MK, RW-G, EK, MM); drafting of the manuscript (MK); critical revision of the manuscript for important intellectual content (MK, RW-G, EK, AS, GS, DT); statistical analysis (MM); provision of patients or study materials (MK); obtaining funding (MK); administrative, technical, or logistic support (MK, MM, GS, DT); and supervision (MK, AS, GS, DT).

Address Correspondence to: Marianna Kong, MD, University of California, San Francisco, Box 1315, 2540 23rd St, Floor 5, San Francisco, CA 94143. Email: Marianna.kong@ucsf.edu.

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