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PATIENT SATISFACTION AND PERCEPTIONS ON TELEHEALTH UTILIZATION

AT FEDERALLY QUALIFIED HEALTH CENTERS IN THE SOUTHEASTERN

UNITED STATES: A MIXED-METHODS STUDY

Alicia Monet Watts

A dissertation submitted to the faculty of the

College of Health Sciences

in partial fulfillment of the requirements for the

Doctor of Philosophy in Healthcare Administration and Education

William Carey University

November 2023

Approved by Committee:

Elizabeth Mahaffey, Ph.D., Chair

Linda Banks, Ph.D.

Judy Prehn, D.Sc.

Jalynn Roberts, Ph.D.

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© 2023
Alicia M. Harris
ALL RIGHTS RESERVED
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PATIENT SATISFACTION AND PERCEPTIONS ON TELEHEALTH UTILIZATION

AT FEDERALLY QUALIFIED HEALTH CENTERS IN THE SOUTHEASTERN

UNITED STATES: A MIXED-METHODS STUDY

Alicia Monet Watts

A dissertation submitted to the faculty of the

College of Health Sciences

in partial fulfillment of the requirements for the

Doctor of Philosophy in Healthcare Administration and Education

William Carey University

November 2023

Approved by Committee:

________________________________
Elizabeth Mahaffey, Ph.D., Chair

________________________________
Linda Banks, Ph.D.

________________________________
Judy Prehn, D.Sc.

________________________________
Jalynn Roberts, Ph.D.
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ABSTRACT

Alicia M. Harris

Patient Satisfaction and Perceptions on Telehealth Utilization at Federally Qualified

Health Centers in the Southeastern United States: A Mixed-Methods Study

Telehealth is a healthcare delivery modality that allows healthcare providers to provide

healthcare remotely through video, audio, or securing messaging. The use of telehealth

extends healthcare access to populations that previously had limited access to care. The

Purpose of this study was to examine patient satisfaction and perceptions of telehealth

utilization in Federally Qualified Health Centers for patients with mental health and

substance use disorders. Using the Rural Telehealth and Healthcare System Readiness

Measurement Framework developed by the National Quality Forum, a convergent mixed

methods research design was used to compare groups to assess patient satisfaction and

perceptions of telehealth utilization. A self-developed instrument was created through a

review of published instruments. Semi-structured interviews were conducted to assess

perceptions of telehealth utilization. The sample consisted of 24 individuals in the

telehealth survey arm and 39 individuals in the non-telehealth survey arm with 13

individuals participating in the semi-structured interview. Descriptive statistics and

independent t-tests were used to analyze quantitative data. Findings revealed that

satisfaction and effectiveness of telehealth were comparable to non-telehealth, whereas a

Significant difference in access to care was observed in the telehealth group. Qualitative

results revealed nine emerging themes and 11 subthemes. Findings of this study support

telehealth as a feasible option to be used in conjunction with non-telehealth visits.

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DEDICATION

I want to dedicate this dissertation to all the little girls and young ladies who think

that achieving a terminal degree is unattainable or impossible. Please know that with

God, ALL things are possible (Matthew 19:26). I am a living witness to this fact. If I can

do it, you can too! Never take the power of hard work, dedication, and most importantly

God for granted.

I also want to dedicate this research to my family, especially my father, Buford E.

Watts III; my mother, Janet Watts; and my deceased cousin, N'Tyrhee Watts. Seeing the

troubles and difficulties you have experienced in life gave inspiration to this well needed

research. While my research may not impact your life significantly or even at all, I pray

that this study at least plants a seed for reform within the healthcare community,

specifically the field of behavioral health.

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ACKNOWLEDGEMENTS

First and foremost, I must acknowledge God because without God by my side,

this entire process would not have been possible. I also want to acknowledge my

dissertation committee Dr. Mahaffey, Dr. Banks, Dr. Prehn, and Dr. Roberts for guiding

me through this dissertation process. Next, I want to acknowledge Dr. Haney, you have

been a great mentor through this entire process by helping me remain encouraged when I

felt like giving up. I want to acknowledge my parents Janet Watts and Buford E. Watts III

for the emotional support that helped more than words can explain. I want to

acknowledge all of my classmates that were going through this dissertation process

alongside of me, you all played a vital role in my success throughout this entire program

and the writing of this dissertation. Lastly, to all of the friends outside of school that

supported me and encouraged me, THANK YOU! While I cannot name each and every

one of you individually, you know who you are, and you know the role you played in

helping me get to the finish line!

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saw

TABLE OF CONTENTS

ABSTRACT................................................. .................................................. .................... iii

DEDICATION................................................. .................................................. ................iv

ACKNOWLEDGEMENTS................................................ ................................................v

LIST OF TABLES.............................................. .................................................. .......... viii

LIST OF ABBREVIATIONS............................................... ............................................ ix

CHAPTERS

I. INTRODUCTION ................................................... ........................................1

Statement of the Problem & Significance..............................................4 Purpose

of the Study ................................................. .......................6 Research Hypothesis/
Questions................... ..................................6 Conceptual
Framework.............. .................................................. ....7 Definition of
Terms.............................................. .................................11
Assumptions.................. .................................................. .................12
Summary................................. .................................................. .....12

II. LITERATURE REVIEW ................................................ ...........................14

Increased Telehealth Utilization in Federally Qualified Health

Centers ........................................... ...................................................14 Increased
Telehealth Utilization and Patient Satisfaction .............26 Increased Telehealth
Utilization and Patient Outcomes................44

III. METHODOLOGY ................................................. ...................................53

Purpose of the Study.............................................. .......................53 Research

Hypothesis/Questions.................... ................................53 Research
Design............... .................................................. ............54
Setting .................................... .................................................. ......56 Participants
and Sampling.......................................... ......................57
Permission.............................. .................................................. ..........57 Participant
Protection.................................... ................................58 Data
Protection............... .................................................. ..............59
Instruments................................. .................................................. .60 Data
Collection ................................................ ................................63 Data
Analysis............... .................................................. ................63
Procedure ................................ .................................................. .....65
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TABLE OF CONTENTS CONTINUED

IV. RESULTS................................................. ...................................................67

Purpose of the Study.............................................. ............................67 Research

Hypothesis/Questions..................... ................................67 Description of
Participants.............. ..................................................67
Results. .................................................. ............................................72 Summary
of Results..... .................................................. ................95

v. DISCUSSION................................................. ............................................97

Summary of Study ................................................. ................................97

Discussion of Results.................... ...................................................98
Implications................................................. ..................................107 Healthcare
Administration Education................... .................108 Healthcare
Administration Practice ............................ ....108 Healthcare Administration
Policy...................................109
Limitations.... .................................................. ...........................110
Recommendations for Future Research ................ .......................110
Conclusions.................... .................................................. .......111

REFERENCES ................................................... .................................................. .............113

APPENDICES ................................................. .................................................. ..............119

Appendix A: Approval Letters.............................................. ................................120 Appendix B: CITI

Training Modules ........... .................................................. .....122 Appendix C: Informed
Consent................................................ ....................................130 Appendix D: Survey
Instrument ........ .................................................. ................133 Appendix E: Interview
Guide ............................ .................................................. 142 Appendix F: Recruitment
Materials.............................................. .........................143 Appendix G:
Permissions ......................... .................................................. ..............145
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LIST OF TABLES

1 Demographic Characteristics................................................ ...................................69

2 Frequencies and Percentages of Characteristics.............................................. .......71

3 Frequencies and Percentages of Telehealth Utilization................................................72

4 RHC-PSS Descriptive Statistics for Telehealth Group............................................... 74

5 RHC-PSS Descriptive Statistics for Non-Telehealth Group ................................76

6 Telehealth Participant Responses and Themes Related to Perceived Benefits.....79

7 Telehealth Participant Responses and Themes Related to Perceived Barriers.....81

8 Telehealth Participant Responses and Themes Related to Perceived Opportunities

for Improvement................................................ .................................................. .83

9 Data Integration Matrix for RQ1 ........................................... ................................85

10 Non-Telehealth Participant Responses and Themes Related to Perceived Benefits

.................................................. .................................................. ...........................87

11 Non-Telehealth Participant Responses and Themes Related to Perceived Barriers

.................................................. .................................................. ...........................89

12 Non-Telehealth Participant Responses and Themes Related to Perceived

Opportunities for Improvement ................................................ ............................91

13 Data Integration Matrix for RQ2 ........................................... ................................93

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LIST OF ABBREVIATIONS

1 COVID-19 Coronavirus Disease 2019 ........................................... ...........................1

2 FQHC Federally Qualified Health Center................................................ ............1

3 NQF National Quality Forum................................................. ...........................7

4 RHC-PSS Rural Health Center-Patient Satisfaction Survey ...........................................60

5 VA Veteran Affairs................................................. ....................................32

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CHAPTER I

INTRODUCTION

In recent years, the inconvenience of driving to doctor's appointments has become

less of a burden, especially for rural and underserved patient populations (Fischer et al.,

2020). Today, one convenient method for health care consumers is telehealth. A desirable

health delivery modality within federally qualified health centers (FQHCs), telehealth can

help increase access to care for rural and underserved populations, thereby helping to

alleviate health care disparities. In fact, Yellowlees et al. (2021) reported that even before

the coronavirus pandemic 2019 (COVID-19) telemedicine was expected to become a

130-billion-dollar industry by the year 2025. COVID-19 is a disease caused by the severe

acute respiratory syndrome coronavirus 2 virus and was discovered in December of 2019

and is a highly contagious respiratory virus that can cause cold, flu, and pneumonia-like

symptoms (Centers for Disease Control and Prevention, 2021).

Equally important, the COVID-19 pandemic continues to propel the growth of

telemedicine utilization by making telemedicine a core health care tool. Mental health is

one healthcare discipline that quickly saw telemedicine as an opportunity to better assist

patients in provider shortage areas, which prompted an increase in the use of tele-mental

health and telepsychiatry. According to Yellowlees et al. (2021), an American Psychiatric

Association survey, taken June 2020, found that 85% of 500 surveyed psychiatrists were

using telepsychiatry with more than 75% of patients, compared to 3% before the COVID-

19 pandemic. Yellowlees et al. suggests there have been increased levels of mental health

conditions such as depression, anxiety, and substance abuse disorder due to the COVID-

19 pandemic. However, there is limited research on the impact of increased telehealth

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utilization on patient satisfaction among the underserved patient population in FQHC

mental health settings.

Telehealth can be defined as utilizing telecommunication services to provide

remote health services, patient education, and public health/administration (US

Department of Health and Human Services, 2020). Telehealth can be broad in nature,

encompassing several modes of delivery such as videoconferencing, audioconferencing,

and secure messaging (Kruse et al., 2017). As the use of technology within healthcare

continues to increase, the utilization of telehealth remains at the forefront because of the

Remote access telehealth gives providers to care for patients. Telehealth extends access to

patients that may have previously had limited access to care, particularly patients in rural

areas (Anthony, 2021; Kruse et al., 2017). McDougal-Ronconi et al. (2022) emphasized

that access to mental health services is a nationwide concern, but the highest concern lies

within the rural health community. Lee et al. (2019) reported that mental health status is

more likely to be worse for individuals living in rural areas than in urban areas, which

reveals the need for increased mental health services in rural populations. Due to the lack

of mental health professionals in rural areas and the heightened stigma associated with

going to a mental health facility, telehealth services play a pivotal role in decreasing

health disparities in rural and underserved areas (Lee et al., 2019; Villalobos et al., 2021).

Kruse et al. (2017) revealed that patient satisfaction is a growing concern within

the healthcare industry. Patient satisfaction plays a pivotal role in healthcare because it

can be tied to reimbursements from the Center for Medicare and Medicaid (CMS).

Similar to traditional methods of healthcare delivery, telehealth relies heavily on patient

satisfaction reports because the patient is the only source that can report whether the
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treatment received met expectations (Kruse et al., 2017). Slightam et al. (2020) stated that

patients often provide positive feedback after utilizing video visits as a healthcare

modality. The convenience of use, the savings in cost and time, and the benefit of time

access to care are several reasons for higher satisfaction with telehealth care. Patients also

report increased satisfaction when utilizing telehealth for mental health care. Patients

with mental health conditions often report feeling more connected and supported. The

Patients feel like the visits are more private and secure and feel reduced treatment stigma.

Patients' perceptions of telehealth could improve the acceptance of telehealth (Slightam et

al., 2020).

Furthermore, increased telehealth utilization has provided increased access to care

for much of the rural population. Furthermore, some of the rural population has chosen to

forgo preventive services that would have otherwise been received prior to the COVID-

19 pandemic, due to the fear of contracting COVID-19 (Simon et al., 2021). Therefore,

telehealth can play a vital role in protecting high risk patients from exposure to COVID-19

19 while maintaining the patient's overall health and well-being (Al-Sharif et al., 2021).

As patients continue to defer healthcare, this issue presents a significant challenge,

especially for FQHCs (Simon et al., 2021).

Limited research is available to explore the long-term effects of deferring

healthcare and the effects that receiving healthcare primarily via telehealth can have on

patient outcomes. Fortney et al. (2021) revealed that only one third of individuals with

complex psychiatric disorders such as bipolar disorder and posttraumatic stress disorder

receive specialty mental health care during a calendar year, and only one tenth of

Individuals with complex psychiatric disorders receive adequate mental health care in
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primary care settings. These statistics are especially concerning for providers in FQHCs

because while 97% of FQHCs offer mental health services on-site, only 12% of FQHCs

staff are psychiatrists or licensed clinical psychologists (Fortney et al., 2021). McDougal

Ronconi et al. (2022) reported that the lack of access to psychologists, psychiatrists, and

psychiatric mental health nurse practitioners in rural areas occurs at much higher rates

than in urban areas. However, the rates of mental health problems affect rural and urban

areas equally, with rural areas experiencing higher rates of substance use disorders and

suicide (McDougal-Ronconi et al., 2022). While increased tele-mental health utilization

can increase access to care for individuals in rural and underserved areas, tele-mental

health utilization can also combat the shortage of psychiatrists and psychologists in these

areas. However, there is limited research on how increased telehealth and tele-mental

health utilization has impacted patient outcomes of individuals with mental health

disorders (Fortney et al., 2021).

Statement of the Problem and Significance

According to the National Quality Forum (2021), patient satisfaction and

experience with telehealth services reporting on the Consumer Assessment of Healthcare

Providers and Systems Survey, is currently in beta testing and has not been field tested on

on a large scale. Due to the lack of telehealth patient satisfaction reporting on a national

level, there is a gap in patient satisfaction research for telehealth services. According to

Kruse et al. (2017), patient satisfaction reporting is not only important for reimbursement

purposes, but patient satisfaction reporting is also important for the improvement of

telehealth services and for ensuring the quality of the service. Moreover, as stated in

Fortney et al. (2021), there is a significant shortage of mental health care professionals
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available for rural and underserved populations. As of 2022, the Health Resources and

Services Administration (HRSA) identified 80 of the 82 counties in Mississippi as mental

Health Professional Shortage Areas (HPSAs; Health Resources and Services

Administration, 2022). According to McDougal-Ronconi et al. (2022), telehealth has the

potential to meet the Institute for Healthcare Improvement's triple aim by (a) improving

patient experience, (b) improving population health, and (c) reducing healthcare

expenditures by reducing costs in transportation, childcare, time away from work, and

other indirect healthcare costs. The Institute for Healthcare Improvement's (2023) triple

aim is a foundational framework to assist organizations and communities in optimizing

health system performance by focusing on experience, population health, and per capita

costs. The increase in telehealth utilization in FQHCs is increasing access to mental

health care for individuals with complex mental health conditions and combating the

widespread shortage of mental health care professionals in these areas (Fortney et al.,

2021). However, there is limited research on how increased telehealth utilization has

Impacted patient satisfaction for individuals with complex mental health in conditions

rural and underserved areas (Fortney et al., 2021).

Villalobos et al. (2021) reported that barriers to mental health care can delay

individuals in receiving needed mental health treatment. In fact, individuals that are

successful in receiving initial mental health care tended to drop out at a high rate within

community health center settings. Nordh et al. (2021) reported that the barriers to mental

health treatment include: lack of trained mental health therapists, elevated treatment

costs, long distances to clinics, and the stigma associated with mental health treatment,

which makes seeking help difficult for the patient. However, telehealth has the capacity
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to address these barriers to mental health care (Anthony, 2021; Kruse et al., 2017;

Villalobos et al., 2021).

Without a doubt, telehealth utilization has significantly increased in federally

qualified health centers across the United States due to the COVID-19 pandemic.

However, the impact of the increased utilization remains unclear and must be addressed.

This research study addresses the impact of increased telehealth utilization on patient

satisfaction because patient satisfaction is a key quality indicator that can support the

continued use of telehealth and tele-mental health care in the future.

Purpose of the Study

The purpose of this study was to examine patient satisfaction and perceptions of

telehealth utilization in FQHCs for patients with mental health and substance use

disorders.

Research Hypothesis/Questions

The following hypotheses and research questions were formulated to provide

guidance for this study:

H0: There is no statistically significant difference in patient satisfaction between groups

of patients utilizing telehealth and not utilizing telehealth in federally qualified health

centers in one Southeastern state for patients with mental health and substance use

disorders.

RQ1: What are patient perceptions of utilizing telehealth services for mental health and

substance use disorder treatment?

RQ2: What are patient perceptions of utilizing in-person health services for mental health

and substance use disorder treatment?

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Conceptual Framework

The Rural Telehealth and Healthcare System Readiness Measurement Framework

is a conceptual framework, developed by the National Quality Forum (NQF), intended to

measure the quality of telehealth in rural areas during public health emergencies and

disasters (National Quality Forum, 2021). However, the elements of the framework are

also applicable to nonemergency telehealth use. The Rural Telehealth and Healthcare

System Readiness Measurement Framework includes five domains: “(1) Access to Care

and Technology; (2) Costs, Business Models, and Logistics; (3) Experience; (4)

Effectiveness; and (5) Equity” (National Quality Forum, 2021, p. 9). The framework

Domains of focus for this study are access to care and technology, experience,

effectiveness, and equity.

Undoubtedly, increased access to care and technology has dramatically impacted

the utilization of telehealth use for rural patients (National Quality Forum, 2021). The

framework addresses several considerations relating to access to care and technology

such as: clinical use cases, geographic distance and travel, telehealth technology and

capacity for communication, broadband issues, basic digital literacy and training, and

system-wide care coordination. Telehealth allows patients access to ongoing primary and

specialty care such as wellness visits and behavioral health visits. Telehealth greatly

reduces barriers to care such as traveling long distances and lack of access to

transportation. Conversely, limited patient access to hardware and software to complete

telehealth visits, limited broadband access, and lack of basic digital literacy can pose

risks to access to care via telehealth.

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Furthermore, the patient experience domain includes the interactions of patients to

assess whether telehealth reflects patient needs and preferences (National Quality Forum,

2021). Key considerations of the patient experience domain include patient choice and

patient acceptance, trust of technology, and receiving care virtually. Patient choice is

the patient option to receive care via telehealth or in person. The framework notes that

Assessing whether patients prefer receiving care via telehealth or in person is important to

consider. Patient acceptability, trust of technology, and receiving care virtually relates

directly to patient experience. The fast transition to virtual care due to the COVID-19

pandemic has affected the willingness of patients to use telehealth services due to

substandard experiences, lack of consistency across platforms, concerns about privacy

and security, and lack of digital literacy. Patient feedback describing the telehealth

experience can provide useful information to improve patient experience.

In addition, the telehealth effectiveness domain addresses the quality and

efficiency of care provided via telehealth (National Quality Forum, 2021). Key

considerations for the effectiveness domain include quality of care for clinical issues

addressed through telehealth, planning for clinical issues not addressed through

telehealth, time to care delivery, and specific care needs of rural patients. The framework

reveals that since telehealth is a modality for delivering healthcare, the standard of care

should be the same for telehealth visits and in-person visits. Therefore, clinical issues that

can be addressed via telehealth, such as behavioral health evaluations and diagnoses,

should have the same quality of care and patient outcomes as an in-person visit.

However, there are clinical issues that cannot be addressed via telehealth, such as

administering vaccinations, and those issues should be referred to local providers for
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care. Telehealth increases patient access to care, which can reduce time to care delivery

for time-sensitive services, such as substance abuse treatment, leading to better patient

outcomes. The framework reveals that rural patients experience specific care needs such

as a higher risk of medical, mental health, and substance use related conditions and

Increased telehealth utilization can increase access to care for these specific care types,

especially when care is limited due to geographic barriers (National Quality Forum,

2021).

Lastly, the equity domain addresses the identification of disparities in access to

care and patient outcomes (National Quality Forum, 2021). Key considerations for the

equity domain includes how quality of care and outcomes differ by certain factors, social

determinants of health, and the impact of telehealth on existing inequities. The

framework reveals that factors such as age, race, gender identity, communication barriers,

geographic location, and literacy can all affect the quality of care for a patient. Telehealth

visits must address these factors similar to how the factors would be addressed during in-

person visits to ensure that care delivery is achieving equitable outcomes. Telehealth

services may also alleviate impacts of social determinants of health related to access to

care and outcomes by allowing a patient to receive healthcare despite having unreliable

or no transportation. Telehealth services can also allow providers the ability to look into

the homes of the patients, providing insight into living conditions, to inform better care

which can ultimately lead to better patient outcomes. Increased utilization of telehealth

services may also be able to reduce health disparities by providing increased access to

care. Conversely, increased utilization of telehealth services may also increase health

disparities by leaving patients unable to afford the devices (eg, smartphones, tablets,
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laptops) needed for telehealth services, thus decreasing access to care (National Quality

Forum, 2021). A model of the Rural Telehealth and Healthcare System Readiness

Measurement Framework is included in Figure 1.

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Figure 1

Rural Telehealth and Healthcare System Readiness Measurement Framework

Note. Reprinted with permission (Appendix G) from Rural telehealth and healthcare
readiness measurement framework: Final report by National Quality Forum, 2021.
(https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_
System_Readiness_Measurement_Framework_-_Final_Report.aspx).

Definitions of Terms

For the purposes of this study, the following terms are defined:

1. Federally Qualified Health Centers (FQHCs): federally funded nonprofit health

center or clinic to serve underserved areas and populations (Healthcare.gov, n.d.).

2. Patient Satisfaction: patient perspective of care, which can be objective or

meaningful to create comparisons of hospitals and other healthcare organizations

(Centers for Medicare and Medicaid Services, 2021)

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3. Telehealth: telecommunications or videoconferencing services to provide clinical

healthcare, patient education, and public health/administration remotely (US

Department of Health and Human Services, 2020).

4. Tele-mental Health: telecommunications or videoconferencing to provide mental

health services (US Department of Health and Human Services, n.d.).

Assumption

One assumption made for this study is that all survey questions were answered

Honestly.

Summary

Telehealth is a healthcare delivery method that allows clinicians to provide

healthcare remotely through methods such as videoconferencing, audioconferencing, and

secure messaging. Due to the COVID-19 pandemic, there has been a significant increase

in telehealth utilization, especially in federally qualified health centers (FQHCs).

Increased telehealth utilization in FQHCs has improved access to care for individuals in

rural and underserved areas, especially individuals with complex mental health

conditions. However, there is limited research on key quality indicators that affect

telehealth such as patient satisfaction and patient outcomes.

The purpose of this study was to examine patient satisfaction and perceptions of

telehealth utilization in FQHCs for patients with mental health and substance use

disorders. Understanding the patient experience (satisfaction) is important because

understanding the experience can lend information to telehealth services regarding how

to best provide these services for mental health and substance use disorder patients in

rural and underserved areas. Examining these relationships can ultimately lead to
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increased access to care and technology, improved patient experience, increased

effectiveness, and improved equity of patient care. Chapter I discusses the background,

problem and significance, purpose, research questions, conceptual framework, definition

of terms, and one assumption for this research study.

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CHAPTER II

LITERATURE REVIEW

Chapter II includes a review of the literature on increased telehealth utilization in

Federally Qualified Health Centers and the effect of increased utilization on patient

satisfaction and outcomes. This review includes the following sections: (a) increased

telehealth utilization in Federally Qualified Health Centers, (b) the effect of increased

telehealth utilization on patient satisfaction, and (c) the effect of increased telehealth

utilization on patient outcomes. The researcher searched for literature about telehealth

utilization in FQHCs using several online databases to include CINAHL Plus,

MEDLINE, and PubMed using the keywords federally qualified health centers, telehealth

utilization, tele-mental health, telepsychiatry, patient outcomes, and patient satisfaction.

Increased Telehealth Utilization in Federally Qualified Health Centers

Telehealth utilization within federally qualified health centers (FQHCs) has

increased significantly. The purpose of a study by Demeke et al. (2020) was to add to the

limited information available on the expansion of telehealth services among FQHCs in

the United States during the COVID-19 pandemic. Demeke et al. revealed that during the

early phases of the COVID-19 pandemic, in-person, outpatient visits, decreased by 60%

in the United States while telehealth services increased by 30%. Demeke et al.

hypothesized that changing telehealth provisions and updated regulations would lead to

expansion of telehealth utilization among FQHCs. The research design used for the

study was a quantitative cross-sectional design. The authors used a sample of 963 of

1,009 HRSA funded health centers that responded to a weekly survey. The setting of the

study was HRSA funded health centers that responded to a weekly survey July 11-17,

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.