JGIM

ORIGINAL RESEARCH
Delivering Urgent Care Using Telemedicine: Insights
from Experienced Clinicians at Academic Medical Centers
Natalie Laub, MD, MSHP1,2,3 , Anish K. Agarwal, MD4,5,6, Catherine Shi, BA4,7,
Arianna Sjamsu, BA8, and Krisda Chaiyachati, MD4,5,7
1
Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 2Center for Pediatric Clinical Effectiveness and Policy
Lab, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 3Department of Pediatrics, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA; 4Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA; 5Leonard Davis Institute of Health
Economics, The University of Pennsylvania, Philadelphia, PA, USA; 6Department of Emergency Medicine, Perelman School of Medicine at the
Hospital of the University of Pennsylvania, Philadelphia, PA, USA; 7Department of Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA; 8New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA.

BACKGROUND: Care delivered using telemedicine has KEY WORDS: telemedicine; provider experiences; urgent care.
been steadily growing in the USA but represented a small J Gen Intern Med 37(4):707–13
fraction of overall visits before the COVID-19 pandemic as DOI: 10.1007/s11606-020-06395-9
few clinicians had been providing care using telemedicine. © The Author(s) 2020
Understanding how experienced clinicians have practiced
telemedicine can help guide today’s exponential adoption
of telemedicine.
OBJECTIVE: The objective of this study was to explore INTRODUCTION
barriers and facilitators to providing effective, high-
Care delivered using telemedicine—virtual visits connecting
quality urgent care using telemedicine (“tele-urgent care”)
from the perspective of clinicians experienced in patients and clinicians through videoconferencing—has been
telemedicine. steadily growing in the USA but represented a small fraction
APPROACH: We conducted semi-structured interviews of overall visits as few clinicians were historically offering
between July 2018 and March 2019 of clinicians who telemedicine to their patients.1, 2 In March 2020, the novel
had been providing tele-urgent care services to patients coronavirus (COVID-19) pandemic resulted in federal and
as a part of their routine clinical practice. Themes were state de-regulation of telemedicine policies to help facilitate
identified using content analysis with a constant compar-
health care’s accelerated shift towards telemedicine to prevent
ative coding approach.
KEY RESULTS: Among the 20 clinicians interviewed, the viral spread and maintain access to care for patients where in-
majority were female (90%) and nurse practitioners (65%). person outpatient practices were limiting who could be seen
We identified four themes related to barriers and facilita- in-person.3–5
tors to providing effective, high-quality tele-urgent care. The monumental transition of the US health care system
Workplace factors such as a strong information technolo- towards telemedicine has been and will continue being a
gy (IT) infrastructure, real-time IT support, an electronic challenge for clinicians. A national survey of chief executive
health record, and a collegial work environment, often officers of US health care systems indicated that 38% of health
virtual, were necessary standards. Communication and
exam techniques from in-person encounters were
systems had no digital health strategy in 2019.6 Even in health
adapted to tele-urgent care including active listening systems with digital health strategies, greater investments in
skills and teaching patients to conduct specific exam ma- technology infrastructure will be required to support clinicians
neuvers virtually. The convenience of tele-urgent care with higher volumes of telemedicine visits, local information
should be preserved to support improvements in access technology (IT) expertise to support their ongoing technical
to care. Finally, patients and clinicians occasionally had needs, and clinicians will need to develop proficiencies and
mismatched expectations about what could or would be clinical skills when caring for patients using telemedicine.
provided during a tele-urgent care encounter. Managing
While not all clinicians have historically used telemedicine,
the added tension that can occur during a telemedicine
encounter was important. some academic medical centers have clinicians who adopted
CONCLUSION: As telemedicine becomes an integral part telemedicine early on. Understanding how experienced clini-
of the care continuum, incorporating and accounting for cians have practiced telemedicine can inform how we train and
these key insights when we train and support clinicians support clinicians who adopt telemedicine into if they are to
will be necessary to provide effective, high-quality care to provide high-quality, safe, and evidence-based care.7
patients in the future. The objective of this study was to identify barriers and
Received May 28, 2020
facilitators to providing effective, high-quality urgent care
Accepted December 3, 2020 using telemedicine (“tele-urgent care”) from the perspective
Published online December 17, 2021 of clinicians experienced in telemedicine.

707
708 Laub et al.: Experienced Provider Insights on Telemedicine JGIM

METHODS qualitative methods researcher (NS). Training included

Study Participants and Setting meetings to develop and refine the interview guide, direct
observation of two interviews, and feedback to enhance
We conducted in-depth, semi-structured interviews of clini- the quality of interviews. Interviews lasted approximately
cians who provided direct-to-consumer, real-time (“synchro- 30 min.
nous”) telemedicine as a substitute for in-person urgent care
appointments at primary care practices or dedicated urgent Data Analysis
care clinics (“tele-urgent care”). Tele-urgent care clinicians
were purposefully interviewed because tele-urgent care has Interviews were recorded, professionally transcribed, and
been commonly employed as a strategy to compete with subsequently coded and analyzed in NVivo 12.0 (QSR
surrounding urgent care and retail health clinics.8 During the International). The interview content was analyzed using
study period, few primary or specialty care clinicians had the constant comparative coding approach.10–12 We began
adopted telemedicine due to restrictive payment policies at our analysis with codes aligned to the interview guide.
the state and federal levels.9 During the coding process, we labeled sections of tran-
Participants were recruited from academic medical cen- scripts with the established codes. Three study team mem-
ters between July 2018 and March 2019 using multiple bers (NS, CS, AS) coded the first four transcripts and
approaches: direct emails, phone calls, and the email list- developed consensus definitions for codes. Two more
serv for the American Telemedicine Association’s Aca- transcripts were coded by the study team (NS, CS, and
demic Medical Center Group. Snowballing techniques AS), resulting in 30% of the interviews being triple-coded.
were used to identify clinicians who delivered tele- Initial transcripts were re-coded based on emerging
urgent care by asking participants if they knew of other themes and final revisions were made to the code defini-
academic medical centers delivering tele-urgent care. Eli- tions. The study team met regularly to examine results and
gible participants included physicians, nurse practitioners, inter-rater reliability, resolving coding disagreements by
or physician assistants who provided tele-urgent care for consensus and clarify code definitions. Records were kept
either or both adult and pediatric patients. Participants of decisions to ensure consistency in coding. The average
were compensated $50 USD for their time. inter-rater reliability was 0.74 with a range of 0.59–1.00,
noting excellent reproducibility.13 Sections of the inter-
Interview Guide Development view transcripts representing the study’s main objectives
were reviewed to discover additional emerging themes
We created a semi-structured, open-ended interview guide and identify representative quotations. All study protocols
(see appendix A) designed to identify barriers and facili- and instruments were reviewed and deemed exempt by the
tators to providing tele-urgent care. The guide was initially University of Pennsylvania’s Institutional Review Board.
created by authors NL, AKA, and KC. The interview
guide was reviewed and pilot tested with two colleagues
specializing in qualitative research. It was revised based
on this feedback. It was then pilot tested with the first two RESULTS
participants. Pilot testing did not identify any significant
A total of 20 clinicians from academic medical centers in the
content issues, so the guide was not revised any further.
Northeast, Midwest, and South were interviewed prior to
Questions were open-ended and included follow-up probes
thematic saturation. Ninety percent were female, 61% were
to allow for participants to expand upon answers as need-
White, 90% practiced in the Northeastern portion of the USA,
ed. Questions included “What do you think are the limita-
50% specialized in family medicine, 65% were nurse practi-
tions of providing care via telemedicine?”; “Describe your
tioners, 30% were physicians, 5% were physician assistants,
experience of providing care through telemedicine.”;
and the average number of years (SD) in clinical practice was
“What do you imagine are the skills necessary to be a
9.7 (9.2) (see Table 1). Four major themes were identified and
good telemedicine provider?”; and “Describe what you
are listed below (see Table 2).
think is different about telemedicine versus in-person
care.” Demographic data, including age, gender, race, spe-
Theme 1: Workplace Factors Can Promote the
cialty, occupation, and years in clinical practice were col-
lected from study participants at the completion of each
Delivery of High-Quality Care
interview. Workplace factors consisted of system-level factors that
were essential for providing high-quality care, including
Data Collection (a) reliable videoconference technology with real-time IT
support; and (b) easy access to the electronic health record
Semi-structured interviews were conducted in person or
(EHR) to review patients’ medical history and communi-
over the phone by three study team members (NS, CS,
cate with other clinicians, either when consulting or to
AS). Interviewers received training from an experienced
JGIM Laub et al.: Experienced Provider Insights on Telemedicine 709

Table 1 Characteristics of Population Interviewed Table 2 Themes and Illustrative Quotes

Characteristic Study group (n = 20) Themes Illustrative quote

Age, mean (SD) 43.9 (8.9) Workplace factors can promote the delivery of high-quality care
Gender, no. (%) Reliable videoconference “I expect to have good quality
Male 2 (10) technology infrastructure with technical connections, quality
Female 17 (90) real-time information technology video, quality sound”
Race, no. (%) support “You have to have champions that
White 11 (61) are willing to put up the costs as
African American 5 (28) far as equipment and enough
Asian 2 (11) technical support when there are
Declined to respond 2 (11) issues. The best way to create lack
Region of practice, no. (%) of buy in is when your equipment
Midwest 1 (5) fails”
Northeast 18 (90) Easy access to electronic health “I do a pre-chart check so that
South 1 (5) records when I am in my visit I can
Specialty, no. (%) quickly get to where I have to get
Family medicine 10 (50) and confirm everything”
medicine 5 (25) Supportive clinical team “We have a lot of support with our
pediatrics 5 (25) environment, even if virtual group. If I ever have questions
Occupation, no. (%) about anything or concerns all I
Nurse practitioner 13 (65) have to do is text one of my
Physician 6 (30) collaborative or my director.”
Physician assistant 1 (5) Clinicians adapted communication and exam techniques from in-person
Years in clinical practice, mean (SD) 9.7 (9.2) care to tele-urgent care encounters
Prior experience with in-person “In order to do Telemedicine, you
hand off patients’ care needs. The need for reliable video- care need some level of experience.
You have to be very comfortable
conference technology with real-time IT support was de- either diagnosing or
scribed in the following ways, recommending a patient to do
certain things”
“My skills have to be sharp
enough by just looking at the
patient and observing, and hearing
I’ve only had one frustrating experience because of the the history, to determine if they are
video. The patient couldn’t see me…we didn’t know sick or not sick.”
Effective use of non-verbal cues “All of the cues the patient just
how to fix the problem. gave me are the same as if I am in
the room with them.”
“I thought maybe I would lose
clues on the video…I found it
interesting that all the cues that I
There needs to be an [IT] person ingrained into the would have picked up on if I was
physically with the person, they’re
team because, and an IT person that understands all the really still there”
intricacies of the connection. When our IT guy was on Practicing intentional and active “Interviewing is the biggest thing
listening for telemedicine because you
vacation, the other people had no idea, they didn’t don’t have the full exam. You
understand all the pieces have to really learn how to be a
good interviewer”
Be a good listener, make sure you
The need for easy access to the electronic health record was are looking at the patient, not
typing. Be open and approachable
highlighted here, and don’t cut them off”
“Give the patient time to talk and
don’t put words in their mouth. I
had to learning that because I am a
Truthfully [tele-urgent care] the easiest visit in the talker”
Medical exam “Try to be very specific, even if it
world, in an office visit there are so many buttons to takes a little longer. Even use your
click and 12,000 things you have to do before you can body as a model. Demonstrate for
them”
sign a chart. In tele-urgent care charting is so easy, you “You can have someone lay down
don’t need 25 minutes, you report the complaint, the and assess their abdomen”
“I’ll say ‘I want you to listen to
diagnosis and the plan, then sign the chart. what I say then do it’ I want you
to sit up straight take a deep breath
Most clinicians highlighted the need to feel connected. This and blow out. When then do that it
allows me to see…can they get a
was described in two ways. First, clinicians believed a sup- full breath, did they cough, did
portive clinical team environment was necessary, even if other they wheeze, can they
immediately speak?”
colleagues or administrators were remote or virtual. Clinicians Confidence “You’re trying to get somebody to
relied on other colleagues to review cases and felt more be confident in what you are
deciding over the computer. If you
confident in their medical decision-making when they could are awkward then maybe the
discuss cases with others. Similarly, clinicians wanted to feel (continued on next page)
connected to the larger health care system. Second, even in a
710 Laub et al.: Experienced Provider Insights on Telemedicine JGIM

Table 2. (continued) were important and essentially learned skills, as none

Themes Illustrative quote received any formal training prior to providing care
through telemedicine. To develop these skills, many cli-
patient would be unsure and not
feel good about it” nicians reported the importance of having prior in-person
Patient education “You need a lot of patient clinical experience before practicing tele-urgent care, such
education, its more talking than
really examining so a lot of patient as,
education is needed in
telemedicine”
“Patient education is a big part of
it. I think sometimes patient In order to do telemedicine, you have to have experience.
education is forgotten.”
The convenience of telemedicine was beneficial to patients You have to feel very comfortable diagnosing or doing
Improved access to care “If there is difficulty getting certain things such as going to the emergency room. Not
somewhere, if they are rural, or having experience could make it very daunting.
they can’t drive it give them
access to care without some of
those other worries”
Potential to avoid the “We don’t have to be face to face
inconvenience or cost of in- to diagnose and treat a lot of
person visits conditions” In telemedicine my skills have to be sharp enough that by
“They don’t have to leave in the
middle of the night and waited in just looking at the patient, observing, hearing the history I
an overcrowded ER” can determine if they are sick, not sick, if they need to be
“Parents don’t have to take off
work, pick their child up from treated right now or if they can try things at home.
school, call the doctor, see if they
can get an appointment, or go to
an ER” Giving the patients time to express their concerns while
Mismatched expectations between patients and clinicians resulted in displaying intentional and active listening was also identified
added tension during the clinical encounter
Patient expectations for “You need to make sure you know as essential to achieve a high-quality virtual visit. Clinicians
convenient prescriptions what you are treating. I remember were more attune to these needs during a telemedicine en-
I had a dad that googled
symptoms and said my ‘son has an counter, as highlighted by the following,
ear infection; can’t you just call in
antibiotics.’ I advised his son to
come in for a visit and his son
actually had pneumonia” Be a good listener, give the patient time to talk. Don’t
Patient with complex needs “Some people come with a lot of put words in their mouth. I had to learn this because I
looking for quick fixes issues and with telemedicine you
can’t always provide that level of am a talker. I would be like ‘is the pain dull’ and I
care.” would be putting words in their mouth and that’s really
Bridging the gap between “I will say, ‘hey can you just do
mismatched expectations me a favor, it will make me feel not what you want to do.
better. I am sorry if I have taken
up your time, but I just want to
take really good care of you, and Based on prior in-person care experiences, clinicians be-
you need to get looked at in lieved the essential skills needed to provide effective virtual
person”
care included non-verbal cues (e.g., body language) and the
creative capacity to help aid patients in examination techniques.

I use my body as a model. I demonstrate (lifting arm)

tele-urgent care model, where continuity of care may be because I can’t do it for them. I show them on my body
disrupted with individual primary care clinicians, clinicians and ask, ‘okay you have a pain here does it go down to
felt patients needed to have continuity of care within the larger here.’
care network. The EHR was used to electronically communi-
cate patient visits and clinical decision-making to patients’
primary care provider or specialists, if they were using the
same EHR. I had a woman palpate her own abdomen…I was like
‘I’m really sorry to tell you this but you likely have
Theme 2: Clinicians Adapted Communication acute appendicitis and need to go to the ED.’ She was
and Exam Techniques from In-Person Care to in the OR within 2 hours.
Tele-urgent Care Encounters
In addition, clinicians identified the need to exhibit
The need for developing virtual competency by using
confidence when they had made a clinical decision be-
lessons from in-person care was frequently discussed.
cause patients might be questioning their diagnosis or
Clinicians suggested that core competencies in virtual care
escalation plan because of the virtual platform. Finally,
JGIM Laub et al.: Experienced Provider Insights on Telemedicine 711

because time spent examining patients was reduced in the prescriptions or diagnostic testing more easily, as expressed
virtual environment, time could be substituted by longer, here,
more in-depth education and counseling relative to what
the clinician would have provided during an in-person
encounter. “I think sometimes with the virtual visit it feels kind of
consumeristic, meaning I paid for this visit, I expect to
Theme 3: the Convenience of Tele-urgent Care get something out of it. Meaning a prescription.
Was Beneficial to Patients
From the clinicians’ perspectives, the convenience aspect of
tele-urgent care made it an important delivery option because
Before I contact the patient, I’m thinking to myself,
patients benefited from better access to care. Patients could
‘Oh god, what if I don’t think they need an antibiotic,
avoid the time inconvenience of seeking an in-person visit as
and this becomes an argument?’
described here,
Clinicians highlighted the perception that patients were
looking for quick fixes and instant gratification.
In our school telemedicine program, parents don’t have
to take off work, we are able to see them and treat them
so that is a huge benefit for our patients.
It’s a world of instant gratification now, with every-
thing at our fingertips. I think people are pleased that
telemedicine is available, and we feel it as clinicians.
For me I can hear the satisfaction in their voice. We live
Patients gain convenience, they don’t have to leave
in a busy world where everyone is multi-tasking.
their home, maybe they’re calling at 2 am, and maybe
transportation is an issue, maybe cost.
The consumerism experienced by tele-urgent care clinicians
resulted in many having to develop routinely used skills when
The ability to provide timely reassurance to a patient or
navigating the tension between providing evidence-based
family was an important aspect of quality which tele-urgent
care, while not wanting to disappoint patients. Many clinicians
care facilitated. Clinicians provided a number of examples
began to routinely emphasize to patients that they wanted to do
where patients were at home worried, such as,
what was best for the health of the patient, even if that meant
they were not going to meet the patient’s expectations.
Number one they gain some reassurance… [Parents]
are really concerned about their child and they want
someone just to look at them. So, I think that’s truly the DISCUSSION
best part of telemedicine.
As health systems integrate telemedicine into how they deliver
care today and beyond, supporting and training the current
When conditions could be managed virtually, the conve-
workforce to be skilled at telemedicine while achieving qual-
nience of tele-urgent care had the potential to reduce patient’s
ity, safe, and evidence-based care will be important. Perspec-
health care costs (e.g., co-pays for some in-person visits).
tives and lessons from more experienced telemedicine clini-
cians can help guide how health systems, educators, and
medical societies approach this challenge. In our qualitative
Sick visits are sometimes just so silly, when I have to
study of experienced clinicians, we identified four key facili-
see them in the office. I’m like ‘yea you have poison
tators and barriers to delivering tele-urgent care.
ivy.’ That you (the patient) have to come in, pay a co-
First, workplace factors such as a strong information tech-
pay and have me look at it to confirm, seems silly
nology (IT) infrastructure, real-time IT support, an electronic
sometimes. Telemedicine would eliminate a lot of that.
health record, and a collegial work environment are necessary
standards. Health systems and administrators need to ade-
Theme 4: Mismatched Expectations between
quately invest in infrastructure (e.g., high-speed broadband
Patients and Clinicians Resulted in Added
and hardware) to support the technical requirements for a
Tension during the Clinical Encounter
high-quality videoconference encounter. While our study is
Clinicians perceived added tension during some telemedicine from the perspective of the clinicians, we recognize that tele-
encounters because of mismatched expectations between them medicine is a dyad interaction between clinicians and patients.
and patients. Clinicians believed that the convenience of using Even if the clinicians have access to the right technology,
telemedicine carried over to patients’ expectations to receive patients may not. Closing this technology gap will be
712 Laub et al.: Experienced Provider Insights on Telemedicine JGIM

important especially as we try to reduce disparities in care convenient form of care. Patients may seek advice for condi-
experienced by low-income and minority patients. Real-time tions they might not have seen a provider for in the first place.
IT support was frequently emphasized. Many of the clinicians For the clinicians we interviewed, the benefits of convenience
interviewed staffed tele-urgent care after hours. Having acces- outweighed the costs of overuse. Should health systems and
sible IT support for virtual support beyond regular business payers create more barriers to care, the gains in access that
hours will important to maintain patient satisfaction and en- patients achieve through tele-urgent care may be lost and
sure effective clinical care. preserving access to care was felt to be an important principle
Administrators and managers need to create a team-like to uphold.
atmosphere and foster connections between colleagues even Fourth, telemedicine visits were occasionally perceived
in a virtual practice. Clinicians commented that clinical and as confrontational. Clinicians were acutely aware of
collegial support were necessary for effective patient care and “pressure” from patients to prescribe medications such
was tied to their satisfaction as a tele-urgent care clinician. At a as antibiotics, and clinicians worried about dissatisfying
broader systems level, tele-urgent care programs should be patients. The risk of dissatisfaction was felt highest
integrated within the greater health care system or care net- among patients that were technologically savvy and were
work to simplify referrals and streamline communications more likely to prefer more convenient care options. The
between tele-urgent care clinicians and primary care providers experience of these clinicians may reflect a higher pro-
or specialists. The EHR facilitated these communications. portion of telemedicine users preferring an informed or
Second, communication and exam techniques can be consumerism style of clinical decision-making, as op-
adapted to tele-urgent care from in-person encounters. Active posed to patients who prefer shared decision-making or
listening skills were used by all clinicians when caring for paternalism.14 Patients who prefer consumerism can be as
patients. While active listening is vital for fostering a thera- high as 28% of patients and is characterized as patients
peutic relationship during in-person encounters, patients may who do not often deliberate treatment options with clini-
have a higher awareness of the clinician’s body language cians and independently choose which treatment plans
during telemedicine encounters. Most videoconferencing should be implemented.15 Patients using tele-urgent care
technology only allows the patient to visualize the clinicians may be more likely to represent patients who prefer a
head to their upper torso. Therefore, patients may be increas- consumerism approach to clinical decision-making.
ingly critical if clinicians look away from the camera, even if At the same time, clinicians want patients to be satisfied
the clinician is reviewing the patient’s medical record on an with their encounter and face pressures to practice
adjacent screen. The videoconference setup limits the patient’s evidence-based medicine. The countervailing forces of
ability to contextualize what the clinician is doing when not patient preferences and clinicians’ desires to achieve high
maintaining eye contact with the camera. Changing clinicians’ patient satisfaction may partly explain the high rates of
body language or eye movements will require frequent feed- inappropriate antibiotics prescribed among tele-urgent
back from patients, simulated patient experiences, and self- care clinicians.16–18 Health care systems and clinicians
awareness. Facilitating these changes is seemingly basic but should consider structured, guideline-driven approaches
will likely be important for generating positive patient to support clinical decision-making within tele-urgent care
experiences. practices. Effective examples include evidence-based con-
Clinicians commonly had patients replicate exam maneu- traceptive prescribing practices using direct-to-consumer
vers that would guide decision-making, including abdominal telemedicine approaches.19 Behavioral economic princi-
examinations and active range of motion maneuvers for joints. ples could be tested through nudges and default options
While clinicians universally recognized that exam options when managing common conditions encountered in tele-
were limited and vital signs were more difficult to collect, urgent care with the goals of reducing overprescribing of
clinicians strived to gather as much information as possible to clinically inappropriate medications and unnecessary test-
guide the patient’s next steps such as watch and waiting or ing. While understanding how to implement, monitor, and
proceeding to the emergency department. Training clinicians enforce evidence-based practice is universally important
to be comfortable with what is possible and impractical during for in-person and virtual encounters, tele-urgent care cli-
telemedicine encounters will be important if telemedicine is to nicians may face unique pressures if patients are more
be used effectively. likely to prefer a consumerism style of decision-making.
Third, clinicians in our study overwhelmingly felt that the Therefore, clinicians will benefit from greater training and
convenience of tele-urgent care was beneficial to patients and practice working with patients who prefer a consumerism
should be maintained. Telemedicine provided access to care approach to care.
that patients expressed having struggled with in the past. Limitations to our study include selection bias. Clinicians
Patients could avoid time spent traveling or higher co-pays who enjoy using telemedicine were most likely to agree to
in emergency department settings when conditions could be participate and early adopters of telemedicine are likely to be
managed using tele-urgent care. At the same time, clinicians positive about their early telemedicine experiences. The par-
recognized tradeoffs that occurred when providing a more ticipants interviewed here likely represent early adopters
JGIM Laub et al.: Experienced Provider Insights on Telemedicine 713

within academic medical centers and thus may have represent Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
a cohort of clinicians who fundamentally support health adaptation, distribution and reproduction in any medium or format,
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seeing virtual care expand. Therefore, they may be less crit- changes were made. The images or other third party material in this
ical of virtual care. Late-adopters or non-adopters were not article are included in the article's Creative Commons licence, unless
interviewed in this study. The sample of clinicians was lim- indicated otherwise in a credit line to the material. If material is not
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findings to today’s clinicians. Additionally, these larger cen- org/licenses/by/4.0/.
ters may have more experience in deploying telemedicine
and resources to support staff and IT which may bias the
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Authors’ Contributions KC and AA conceived and designed the 4324/9781315013015-30
study. KC obtained grant funding. KC, AA, and NL supervised the 15. Murray E, Pollack L, White M, Lo B. Clinical decision-making: Patients’
conduct of the trial and data collection. KC and AA undertook preferences and experiences. Patient Educ Couns. 2007; doi:https://doi.
recruitment of participating centers and participants. KC, AA, NK, org/10.1016/j.pec.2006.07.007
CS, and AS managed the data, including quality control. KC, AA, NL, 16. Krupinski E, Dimmick S, Grigsby J, et al. Research recommendations
CS, and AS provided statistical advice on study design and analyzed for the American Telemedicine Association. Telemed J E Health.
the data. NL drafted the manuscript, and all authors contributed 2006;12(5):579-589. https://doi.org/10.1089/tmj.2006.12.579
substantially to its revision. All authors take responsibility for the 17. Ray KN, Demirci JR, Bogen DL, Mehrotra A, Miller E. Optimizing
paper as a whole. Telehealth Strategies for Subspecialty Care: Recommendations from
Rural Pediatricians. Published online 2015; doi:https://doi.org/10.
1089/tmj.2014.0186
Funding Eisenberg Scholar Research Award from the University of 18. Uscher-Pines L, Kahn JM. Barriers and Facilitators to Pediatric
Pennsylvania’s Robert Wood Johnson Clinical Scholars Program. Emergency Telemedicine in the United States. https://doi.org/10.1089/
tmj.2014.0015
19. Jain T, Schwarz EB, Mehrotra A. A study of telecontraception. N Engl J
Compliance with Ethical Standards: Med. 2019; doi:https://doi.org/10.1056/NEJMc1907545

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