Qualitative Study Assesses Perceptions of e-Visits in Older Adults


Although older patients generally accept electronic visits (e-visits) conducted via asynchronous messages, nearly two-thirds said they prefer visit types with synchronous dialogue.

Older adults from diverse backgrounds identified attitudes, barriers, and preferences in using patient-initiated messaging with their providers, according to a recent qualitative analysis published in JMIR Aging.

The researchers assessed patients’ knowledge and perceptions surrounding billable e-visits compared with unbillable portal messages and other types of visits. To meet the criteria of an e-visit, a provider must meet specific factors, such as making a clinical decision that typically would have been provided in the office. E-visits must also be patient initiated, the study authors noted. 

“The majority of patients in this study were accepting of the idea of e-visits—billable, asynchronous patient-initiated messages—and willing to try one, despite preferring synchronous visits,” the authors wrote.

However, e-visits are only available to patients who use patient portals. Unequal use of portal tools by certain populations may worsen health disparities, they added. Their primary study aim was to understand patient perceptions of e-visits, including their perceived utility, barriers to use, and care implications, with a focus on vulnerable patient groups.

Study researchers conducted 20 in-depth qualitative interviews (13 men, 7 women) from April 2021 to June 2021. The median (IQR) age was 74 (68.5-77.8) years. All participants had active patient portal accounts, and 70% had Medicare insurance. Interviews were conducted by Zoom unless a participant was unable to use video, in which case the interview was conducted by telephone.

To ensure a diverse sample, the researchers identified patients who met the following criteria: Latinx ethnicity, African American race, had MediCal (Medicaid) insurance, did not speak English, and lived in rural areas. At least 2 patients were selected from each group.

Based on their analysis, the researchers identified 4 overarching themes:

  • Older patients were generally accepting of e-visits and were willing to try them; they also agreed that providers should be fairly compensated for time spent on medical decision-making, whether in a synchronous or asynchronous visit
  • Nearly two thirds of participants voiced a preference for synchronous communication; in many cases, in-person visits were preferred.
  • Thirty-three percent reported technical barriers in accessing and using e-visits
  • Participants articulated a variety of concerns, such as confusion over the name “e-visit,” when to choose this type of visit in the patient portal, and discomfort expressing medical questions in writing; financial barriers were not a common theme

Older adults are at particular risk for facing health disparities because of decreased access to digital health technologies, the authors wrote. To make these tools more attractive and accessible to older patients, they suggested these solutions: 

  • Make names of billable visits more descriptive to help patients understand the difference between an e-visit and a traditional patient portal message
  • Do not ask patients to determine whether their message clinically qualifies as a billable e-visit or a nonbillable patient portal message; give them a single point of entry. 
  • Let patients write e-visit queries in their preferred language
  • Provide access to patients’ caregivers to submit e-visit requests on behalf of their loved ones
  • Have health care organizations explain that e-visits may require out-of-pocket costs, depending on insurance type

The investigators noted study limitations. The sample size was small, and most participants lived in an area with high rates of digital literacy. In addition, interpretation of interview transcription content might have been biased due to individual interviewer implicit biases. Finally, since many participants had Medicare insurance, findings might not be generalizable to other patient groups.

Despite these limitations, the authors said their study is an important step toward understanding patient perceptions around e-visits, a relatively new asynchronous form of digital health care.

“As health systems shift toward providing more virtual care, it is crucial that we understand the interest and ability of vulnerable patient groups to use these digital tools so as to prevent worsening health disparities,” the authors concluded. “Billable e-visits may encourage care delivery organizations to innovate alternate means of communicating with and engaging patients.”


Judson TJ, Subash M, Harrison JD, et al. Patient perceptions of e-visits: qualitative study of older adults to inform health system implementation. JMIR Aging.Published online May 26, 2023. doi:10.2196/45641

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