Diagnosing at a distance: How telemedicine impacts the diagnostic process

Abstract

Background

The rapid expansion of telemedicine has reshaped healthcare delivery, offering increased accessibility and convenience. However, its impact on the diagnostic process is still undergoing evaluation. This study explored key stakeholder perspectives to enhance understanding of telemedicine's role in the diagnostic process.

Methods

We conducted semistructured interviews with 34 subject-matter experts (SMEs) in telemedicine and practicing clinicians across various healthcare organizations and 10 patients with prior telemedicine experience. Using inductive qualitative content analysis, we identified themes related to facilitators and challenges in the diagnostic process via telemedicine encounters.

Results

SMEs and clinicians noted telemedicine's potential to improve access and enhance continuity of care, but they raised concerns about diagnostic accuracy due to the absence of hands-on physical exams and challenges in managing diagnostic uncertainty. Specifically, clinicians described relying more on additional testing, patient self-reports, and scheduling in-person follow-ups to compensate. Patients emphasized the convenience and accessibility of telemedicine, particularly for those with disabilities, and valued the ability to communicate with clinicians in a familiar environment. However, few patients had received a new diagnosis via telemedicine; and many preferred in-person visits for new or complex concerns. Additionally, barriers related to digital literacy, technology challenges, and incomplete follow-up on diagnostic testing emerged as critical factors influencing telemedicine's effectiveness in diagnostic decision-making.

Conclusions

Our qualitative study of stakeholder perspectives underscores certain limitations of telemedicine in the diagnostic process and outlines the need to consider strategies to enhance the effectiveness of diagnostic decision-making in telemedicine.

Keywords

Diagnosis diagnostic accuracy diagnostic errors telemedicine

Background

Telemedicine, the delivery of clinical care remotely,¹ expanded rapidly during the COVID-19 pandemic^2,3 facilitated by advancing technologies, increased accessibility to broadband internet, and the increasing adoption of digital health platforms.⁴ However, its integration into the diagnostic process may disrupt the traditional clinical approach to making a diagnosis. The diagnostic process is defined as a complex, patient-centered, collaborative activity that involves information gathering and clinical reasoning with the goal of determining a patient's health problem.⁵ This process occurs over time and within the context of a larger healthcare work system. It is essential to understand the impact of telemedicine on diagnosis and implications for clinicians and patients to determine safe telemedicine practices.^6–8

Although telemedicine has proven benefits,^9,10 it faces several challenges and limitations that may impact diagnostic safety.^11–13 For instance, physical exams may be limited virtually, and subtle signs detected in-person might be overlooked in telemedicine visits. Technological barriers, such as poor connectivity or limited device access, can hinder remote consultations, especially in rural or underserved areas. Digital literacy, a barrier to health equity,^14–16 varies among patients and providers and can affect the quality of interactions and the accuracy of diagnoses. While clinically, observations and physical exams are often essential for a comprehensive assessment, there are emerging data that some diagnosis-related tasks (e.g. virtual physical exams,^17–19 technology advancements²⁰) are translatable to telemedicine visits.^21–24

Telemedicine visits, when compared to face-to-face visits, result in similar or fewer numbers of emergency department visits, hospital visits, less prescribing and fewer diagnostic tests and imaging for patients.^3,25,26 Studies also report high levels of diagnostic concordance between telemedicine and in-person visits,^27–30 suggesting that for some symptoms, the diagnostic process in telemedicine settings may be as reliable as in-person assessments, particularly when physical examination is less critical. Some specialties report high accuracy rates for diagnosis (>80%).^25,28 Telemedicine, when implemented properly, shows clinical effectiveness for certain dermatological and ophthalmic conditions.²⁶ Despite promising work, concerns remain about the use of telemedicine for other diagnoses and ways in which it may alter elements in the diagnostic process.³¹ In this study, we explored stakeholders’ (i.e. clinicians, patients and subject matter experts (SMEs)) perceptions on the role of telemedicine in the diagnostic process.

Methods

Study setting and population

We recruited 34 SMEs and front-line clinicians with ≥1 year of telemedicine experience from U.S. academic and large hospitals, affiliated clinics, and emergency rooms via snowball sampling. SMEs were identified based on expertise in telemedicine and/or diagnostic errors (e.g. publications, recognition). Clinicians were recruited from two participating healthcare organizations. We additionally recruited 10 patients who had previously used telemedicine visits, with five recruited from each participating site through social media posts and flyers to increase visibility and participant enrollment. Potential participants were contacted by email with up to two reminders at two-week intervals.

Interview guide development

Three semistructured interview guides were developed over six months (Appendices A–C). The SME interview guide included 22 questions across eight domains: (1) current telemedicine practices, (2) patient–provider encounter, (3) performance and interpretation of diagnostic tests, (4) follow-up and tracking of diagnostic information, (5) subspeciality and referrals, (6) patient-related factors, (7) technology used in telemedicine and (8) identification and tracking of missed opportunities in telediagnosis. The clinician guide included 15 questions in two domains: (1) diagnostic safety concerns, and (2) and two case scenarios to explore telemedicine diagnostic approaches. The patient interview guide included nine primary questions with probes across five domains: (1) telemedicine use and access, (2) onboarding and technology experience, (3) patient experience with video visits, (4) diagnostic experiences in telemedicine, and (5) care coordination and improvement perspectives.

Data collection and analysis

An experienced qualitative methodologist conducted Zoom interviews from January 2023–April 2024, which were audio-recorded, and transcribed verbatim. We conducted inductive qualitative content analysis, allowing codes and categories to emerge from the data. Patient interviews were analyzed separately from the SME/clinician interviews. The interviewer conducted the primary data analysis, developed open codes, grouped them into categories, and iteratively refined themes. A second coder independently coded 10% of random interviews. The research team reviewed themes to resolve discrepancies and ensure alignment with the data.

Results

We contacted a total of 93 potential participants (SMEs n = 28; clinicians n = 55; patients n = 10), of those 17 SMEs, 17 clinicians, and 10 patients agreed to interviews. Forty-four participant interviews were included in the final analysis. SMEs represented emergency medicine (n = 3), internal medicine (n = 9), family medicine (n = 3), healthcare operations, policy, informatics, health equity, and patient safety. Clinicians self-identified as internal medicine (n = 7), hematology/oncology (n = 2), emergency medicine, family medicine, gastroenterology, palliative medicine, community medicine, and pulmonary medicine. SMEs and clinicians were analyzed together; patients were analyzed separately. Subanalyses by SMEs’ expertise and clinician subspecialties did not reveal differences across themes. We cannot determine if this was due to selection bias, sample size, and/or high agreement across fields.

Qualitative analysis of SME/clinician interviews highlighted telemedicine challenges related to the diagnostic process, including limitations related to physical exams and testing and patient barriers (Table 1). Several benefits were identified that supported the diagnostic process and patients’ needs (Table 2). These factors shaped the telemedicine diagnostic process and are discussed below. Separately, patients indicated overwhelmingly positive experiences with telemedicine; and the majority use telemedicine visits for the continuation of care or for managing chronic conditions.

Table 1.

Telemedicine challenges the diagnostic process (input from experts and clinicians).

Theme	Subtheme	Supporting quotes
Diagnostic process	Physical exam	“…there certainly is … a lot of information that one can glean from in-person interactions … that one does not see when being on a video platform.” (SME 10) “I am concerned … that the lack of inputs from physical exam to laboratory testing … decreases information and therefore increases the risk of misdiagnosis….” (SME 4) “95+% of everything is based on the history the patient provides, and it's equally good or better over video.” (SME 15)
	Diagnostic testing	“…If I order labs on a video visit … I sort of rely on the patient making it to the lab … whereas if I'm in person … there's a higher likelihood that the person will just walk over to the lab and get it done…” (SME 7) “…I have a much harder time getting people to get their labs done … over telehealth…” (SME 13)
	Clinician telemedicine training	“…people aren’t getting fully trained on how to do telehealth visits … they get trained on the technology and not really any of the skills of it…” (SME 11)
Patient-related challenges	Patient characteristics	“…I believe that age and overall comorbidity just make things harder just because it (sic) lengthens the visit, it makes it more complex…” (SME 3) “…patients with limited English proficiency … tend to be a bit more concerned, especially when, like, interpreters are involved. There might be something lost … in it” (SME 7)
	Digital health literacy	“…sometimes they refuse to do the visit because of past experience and not being able to understand how to work the technology … it's a broad spectrum of people…” (SME 9)
	Technology access/use issues	“There is no team-based care in telehealth. People [providers] have to do everything themselves … I would say establishing team-based care. So the provider doesn’t have to do technical support and can actually focus their brain on diagnosis” (SME 13) “If there's something happening in real time, it's generally up to the provider … to figure out how to navigate that…” (Clinician 13) “It's quite challenging. And when we first started here in our clinic, we actually didn’t have the administrative support…” (Clinician 15)

Table 2.

Telemedicine benefits to patients and the diagnostic process.

Theme	Subtheme	Supporting quotes
Benefits to the diagnostic process	Access to underserved populations	“…there's opportunity for us to see the patient in their own environment, be able to like see them interact with their family because those environmental factors do impact like the patient's wellbeing….” (SME 2) “…I could see not only them … but also … their environment …. you’re not only assessing the patient, you’re assessing the environment that the patient is in … you can assess that for safety reasons….” (SME 9) “… I would always say it's better than nothing … To virtually see them than not see them at all … it's better than nothing.” (Clinician 11) “… I think video visits is just another way to triage patients and, and to try and get them to the right level…of care.” (Clinician 6)
	Triage care appropriately	“You can’t compare telehealth and virtual care directly to an office. You have to compare to what would the patient have done if it wasn’t available … and that's really, really important.” (SME 3) “Our healthcare system was already pretty fragmented and not delivering for patients, and so maybe we’re doing a better job helping patients triage” (SME 10) “I'm triaging yes. But I'm also treating….” (Clinician 7)
	Patient–provider relationship	“…being able to have virtual care options … usually increases my access and availability to take care of them … I think that improves overall quality because you have more touchpoints with the patient, and it improves the relationship because they feel more connected to you…” (SME 3)
Benefits to patients	Accessibility	“…I have patients where it's really hard for them to get into clinic … distance is an issue, it's a, wintertime, weather is an issue here in rural New England … patients with lower socioeconomic status where they may not have a car….” (SME 5)
	Feasibility	“…like half of the patients who call me are actually at work, and so they just step away for 10 … not having to disrupt their workday or lose a day of work.” (Clinician 14)
	Economic benefit	“…I think, like, economical benefits are, like, the time cost of getting to our clinic waiting … paying for parking … lose 2 hour of work wages … so like a telehealth visit … I would say that would be the economical benefit.” (Clinician 14)

SME and clinician perspectives on challenges of telemedicine during the diagnostic process

Patient characteristics

SMEs/clinicians (n = 15) identified several patient characteristics (e.g. age, literacy, income, culture) that may impact a patient's ability to fully engage in a telemedicine visit and negatively impact the diagnostic process: “…I believe that age and overall comorbidity just make things harder just because it (sic) lengthens the visit, it makes it more complex…” (SME 3). According to SMEs/clinicians, older patients may have limited knowledge, access, and/or ability to use telemedicine technology. Additionally, they indicated that comorbidities and language barriers may complicate the diagnostic process by requiring more time than what is allotted for a telemedicine visit. “…patients with limited English proficiency … tend to be a bit more concerned, especially when … interpreters are involved. There might be something lost … in it” (SME 7).

Twenty-two participants cited digital health literacy and technology access/use issues (i.e. broadband access, smart device use, and troubleshooting) as reducing clinical time and limiting opportunities to discuss patient concerns in detail.

…I log onto the link, no one's there. I then have to chase them by calling them. You have to find someone to help them log on. So, you’ve lost like the first 5 to 10 min of the visit, and then I have to be with the next person in 20 minutes again…. (Clinician 12)

Physical exam

Participants (n = 18; SMEs = 10, clinicians = 8) agreed that limited physical examination makes diagnosis by video challenging, increasing reliance on perception and risk of missed or incorrect diagnosis: “… the subjective portion becomes so much more important… when it's over video because like, I can’t lay hands, I can’t objectively do parts of the physical exam…” (SME 8).

The absence of a physical exam limits information gathering, and it becomes more likely that clinicians narrowly focus only on the more apparent symptoms to make a diagnosis: “…people are more likely to … jump to what is an obvious diagnosis … premature closure … Also, you can sometimes miss danger signs because you’re not examining a patient” (SME 13).

In general, SMEs/clinicians acknowledged that this transition from in-person to widespread utilization of telemedicine was sudden and unexpected. Clinicians have needed to learn in real time how to make a diagnosis without having physical contact with their patients.

“…because you’re on telemedicine … it's a different kind of risk tolerance and risk threshold that many clinicians have not been trained for and have just kind of had to learn…” (SME 6).

Additionally, SMEs/clinicians indicated that the lack of a physical exam impacts the ability to identify differential diagnoses. Clinicians may over-rely on testing or medication, based on that lack of information: “…it [physical exam] really determines which way you go on so many things. And so you end up over ordering, you end up overmedicating” (Clinician 2).

Despite these challenges, nine participants (SMEs = 5, clinicians = 4) indicated that a clear and concise history from patients and their families can replace the need for a physical examination. They firmly believed that a good history outweighs the need for a physical exam to achieve an accurate diagnosis. “…95+% of everything is based on the history the patient provides, and it's equally good or better over video…” (Clinician 15). Some participants indicated that providers’ experience and diagnostic skill set can assure diagnostic safety. Others noted that younger providers are comfortable using diagnostic testing and detailed history for diagnosis without the need for a physical exam: “…lot of people in my generation and younger, just because we have access to lab and imaging, a lot of tech data, you know, a physical exam doesn’t change much” (SME 10).

Diagnostic testing

Several participants (n = 18; SMEs = 9, clinicians = 9) described their concerns about ordering diagnostic testing following a telemedicine visit. Providers indicated that patients on site are more likely to follow through with testing versus when testing is ordered during a telemedicine visit.

… If I order labs on a video visit, … I sort of rely on the patient making it to the lab … whereas if I'm in person … there's a higher likelihood that the person will just walk over to the lab and get it done…. (SME 7)

SMEs/clinicians indicated a concern that the ease and convenience of telemedicine visits may introduce delay—patients still need to physically visit a lab for testing. This delay could potentially impact the timeliness of diagnosis and treatment, introducing more opportunities for errors. For example, “I have more confidence in-person than I do on televisit … They may or may not be able to go to the lab … there's just a lot of opportunities for errors or delay” (Clinician 13).

Some emphasized the value of baseline labs, where a single result can potentially alter a treatment plan. However, there are no systems in place to ensure timely completion. Clinicians must rely on their communication skills to help patients understand the importance of lab work, encouraging timely follow-through on testing for diagnosis: “…I have a much harder time getting people to get their labs done … over telemedicine…” (SME 13).

SME and clinician perspectives on benefits of telemedicine to the diagnostic process

Access for underserved populations

Eighteen SMEs/clinicians indicated that telemedicine allows healthcare systems to reach a wider range of patient populations that might otherwise have limited access to in-person visits and be vulnerable to diagnostic delays. For example, “It's better than nothing … To virtually see them than not see them at all, … it's better than nothing” (Clinician 11). They (n = 12) also noted that the accessibility of telemedicine made it more likely for patients to seek care. This was particularly relevant for patients situated in rural areas or with limited transportation options. Telemedicine provides an opportunity for patients to have access to a primary care doctor: “…in certain demographics … less than 50% of patients have a primary care provider … strong parts of virtual care that should be underlined is it enables this easy access…” (SME 1). Furthermore, SMEs/clinicians also indicated that telemedicine provides opportunities to collaborate and coordinate patient care between different specialties across various geographical locations: “…if you have … specialists in different places, they can collaborate much easier over telemedicine than it is over (sic) in person … what we call care collaboration” (SME 11).

Appropriate triage

Participants (n = 18, SME = 10, clinicians = 9) stated that video telemedicine primarily involves triaging and directing patients to a higher level of care (e.g. emergency room, urgent care). It is a means for patients to connect with a clinician in a relatively short time and be directed to take next steps. “…I think video visits is (sic) just another way to triage patients and, and to try and get them to the right level … of care” (Clinician 6). Telemedicine is a means to connect patients with a provider in a relatively short time and guide patients to the next step of care, either self-care or a higher level of care.

Strengthening patient–provider relationship

SMEs and clinicians (n = 12) noted improved relationships between patients and clinicians using telemedicine as a benefit to the diagnostic process. Clinicians may build trust with patients via telemedicine by allowing increased focus on the patient with fewer clinic distractions. “…virtual care options … increases (sic) my access and availability to take care of them … that improves overall quality because you have more touchpoints with the patient, and it improves the relationship because they feel more connected to you…” (SME 3). Of note, five participants disagreed and indicated that telemedicine visits have made it harder to build rapport. According to them, face-to-face interaction is a superior way to facilitate relationships with patients. “I do think … telemedicine takes away from the … rapport building between the patient and the physician…” (SME 10).

Patient perspectives on the influence of telemedicine on the diagnostic process

All patients interviewed highlighted the convenience of telemedicine—especially for patients with disabilities—less wait times and no parking or gas costs. As one commented, “It is convenient, especially if the facility is far away, especially if you are not an in-person type of person … It just makes it simpler.” Patients indicated that telemedicine allows them to be comfortable in their own environment making the visit more productive: “The quality is much better. I’m calm. I’m able to focus on everything that I need to be said, and she hears me…” (Patient 10). Patients also reported that video provided a personal face-to-face experience and allowed for relationship building between clinician and patient.

When asked questions specifically about the diagnostic process (e.g. testing, new diagnosis, physical exam), only four patients had received a new diagnosis via telemedicine visit, and each indicated that the diagnosis was mild (e.g. ear infection). Participants explained having indicators for when to seek care in person—either a personal threshold, such as minor issues or initiating care with a new provider, or a perception of institutional/clinician rules. For instance, one participant told us about a preference to see a new provider in-person but also mentioned understanding that “In the [clinic], you have to go in-person for new symptoms” (Patient 7). Another told us: “I use discretion on when to go inside and when to use a, a video. You know, if I’m having like some symptoms that I never had before, then I go inside to get checked out” (Patient 3). Finally, eight indicated that testing is easy, as patients can go to the closest lab to complete testing, though it can be burdensome for patients with disabilities.

Discussion

This study explored stakeholder perspectives on telemedicine in the diagnostic process, highlighting both benefits and challenges. Clinicians, SMEs, and patients acknowledged telemedicine's potential to enhance access and continuity of care, but concerns emerged about diagnostic limitations, particularly on the diagnostic process (e.g. the inability to perform physical examinations) and managing diagnostic uncertainty (e.g. increased reliance on testing, patient self-reports, or scheduling in-person follow-ups). Digital literacy and technology barriers reduced telemedicine's effectiveness in diagnostic decision-making (e.g. patient difficulty navigating telemedicine platforms, challenges troubleshooting technical issues, and poor internet connectivity disrupting consultations) by reducing actual clinical time and data collection. Patients, while valuing telemedicine's convenience and accessibility, showed a preference for in-person care when facing new or complex symptoms, suggesting an intuitive understanding of telemedicine's diagnostic limitations. This alignment between provider and patient perspectives suggests boundaries for appropriate telemedicine use for diagnosis.

Prior research supports telemedicine's ability to achieve diagnostic accuracy comparable to in-person visits for specific conditions, particularly in specialties and particular organ systems or exam types (e.g. only required observation rather than physical examination).^12,18,32 However, concerns about missed or delayed diagnoses in telemedicine settings remain.¹² Our findings align with existing literature suggesting that the absence of hands-on physical examination can impact diagnostic confidence.^6,33 However, evolving technologies, such as virtual physical exam techniques, remote monitoring, and wearables offer alternative solutions for data collection during a telemedicine visit.^10,17,34 SMEs and clinicians also expressed concerns about in-person testing and referral completion following a telemedicine visit and their impact on the diagnostic process. The literature shows that, while follow-up rates are low for all test types across all visit modalities, rates are especially low for telemedicine.¹⁶ Incomplete follow-up presents a diagnostic safety challenge, which may be especially concerning for clinicians during telemedicine encounters making decisions about next steps. While some challenges to the diagnostic process identified in this study (e.g. incomplete follow-up on diagnostic testing, reliance on patient self-report) may also occur in face-to-face clinical encounters, telemedicine may amplify these difficulties due to the physical and logistical distance between patient and clinician.

To optimize telemedicine's role in diagnosis, healthcare systems should prioritize the development of clear protocols specifying when telemedicine is appropriate versus when in-person evaluation is necessary. These protocols should consider both clinical factors and patient-specific characteristics that may influence diagnostic accuracy in virtual settings. This is especially true for patients who may have their own personal threshold for deciding between telemedicine and in-person, based on previous experience, personal beliefs, or perceptions about their clinician's preferences for when it is appropriate to use telemedicine. Additionally, healthcare organizations should implement robust follow-up mechanisms, enhanced training in virtual assessment techniques for clinicians, and strategies to mitigate digital literacy and technology barriers that disproportionately affect vulnerable populations. Given the pace of technological advancement, protocols should be reviewed on at least an annual basis to ensure they remain current and reflect evolving clinical experience and emerging telemedicine capabilities.

Although telemedicine has the potential to reduce healthcare disparities by increasing access, it also introduces new challenges related to digital literacy, technology access, and disparities in broadband availability.^35–38 We found that SMEs and clinicians identified certain populations (i.e. older adults and those in rural or medically underserved areas) that may face barriers to engaging effectively in the diagnostic process via telemedicine. This aligns with broader concerns in the literature regarding disparities in telemedicine adoption. To address these challenges, healthcare systems must develop interventions to improve digital literacy, such as offering technical support during virtual visits.³⁹ Expanding broadband access and ensuring that telemedicine platforms are user-friendly across diverse patient populations are also critical.

Our qualitative study underscores telemedicine's current limitations in diagnosis. Providers and patients recognize that in-person visits remain essential when physical examinations are required for accurate diagnosis. Clinicians compensated for diagnostic uncertainty by ordering additional testing, relying heavily on patient self-reports, and scheduling in-person follow-ups—potentially increasing inefficiency and utilization. This uncertainty-driven follow-up pattern warrants further investigation. Future research should explore the impact of telemedicine-based diagnosis on patient outcomes, emerging remote diagnostic technologies, and follow-up care patterns. Findings can inform healthcare systems telemedicine models that optimizes access, convenience and diagnostic accuracy.

Conclusions

Although telemedicine offers significant potential, challenges remain in ensuring the safety of the diagnostic process and equity. To optimize telemedicine's role in diagnosis, healthcare systems should prioritize clinician training in virtual assessment techniques and implement robust follow-up mechanisms to mitigate uncertainty. Future research should explore the impact of telemedicine-based diagnosis on patient outcomes, investigate emerging technologies that enhance remote diagnostic capabilities, and assess long-term trends in telemedicine utilization and safety. These findings can help healthcare systems work towards a model that balances accessibility, diagnostic accuracy, and patient-centered care.

Supplemental Material

sj-docx-1-jtt-10.1177_1357633X261466000 - Supplemental material for Diagnosing at a distance: How telemedicine impacts the diagnostic process

Supplemental material, sj-docx-1-jtt-10.1177_1357633X261466000 for Diagnosing at a distance: How telemedicine impacts the diagnostic process by Traber D Giardina, Umber Shahid, Rosann T Cholankeril, Jan A Lindsay, Hardeep Singh and Daniel R Murphy in Journal of Telemedicine and Telecare

Supplemental Material

sj-docx-2-jtt-10.1177_1357633X261466000 - Supplemental material for Diagnosing at a distance: How telemedicine impacts the diagnostic process

Supplemental material, sj-docx-2-jtt-10.1177_1357633X261466000 for Diagnosing at a distance: How telemedicine impacts the diagnostic process by Traber D Giardina, Umber Shahid, Rosann T Cholankeril, Jan A Lindsay, Hardeep Singh and Daniel R Murphy in Journal of Telemedicine and Telecare

Supplemental Material

sj-docx-3-jtt-10.1177_1357633X261466000 - Supplemental material for Diagnosing at a distance: How telemedicine impacts the diagnostic process

Supplemental material, sj-docx-3-jtt-10.1177_1357633X261466000 for Diagnosing at a distance: How telemedicine impacts the diagnostic process by Traber D Giardina, Umber Shahid, Rosann T Cholankeril, Jan A Lindsay, Hardeep Singh and Daniel R Murphy in Journal of Telemedicine and Telecare

Footnotes

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

ORCID iDs

Traber D Giardina

Rosann T Cholankeril

Hardeep Singh

Daniel R Murphy

Human ethics and consent to participate declarations

This study was approved by Baylor College of Medicine's Institutional Review Board (Protocol H-48086) and the Research and Development Committee at the Michael E. DeBakey VA Medical Center. Verbal informed consent was obtained from all participants prior to participation.

Contributions

DR, HS, TG, and JL conceptualized the study. All authors contributed to the development of the interview guide and recruitment materials. RC and US conducted the interviews and data collection. US and TG supported data analysis and interpretation. TG contributed to the literature review. TG drafted the initial manuscript. All authors contributed to drafting and revising the manuscript and approved the final version. DR and HS provided supervision and guidance throughout the project.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially supported by the use of facilities and resources at the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (Grant No. CIN13-413). Dr Singh is funded in part by the Agency for Healthcare Research and Quality (Grant Nos. R01HS028595 and R18HS029347). Dr Giardina is funded in part by the Agency for Healthcare Research and Quality (Grant No. R18HS029356). Dr Murphy is funded in part by the Agency for Healthcare Research and Quality (Grant No. R01HS028595). Dr Lindsay is funded in part by a VA HSR&D grant (Grant No. IIR-18-007).

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Data availability statement

The qualitative interview data generated and analyzed during the current study are not publicly available due to the presence of sensitive and potentially identifiable information from participants. Deidentified excerpts relevant to the findings are included within the article.

Supplemental material

Supplemental material for this article is available online.

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