The study used a qualitative, hermeneutic methodology to explore what it means for patients and providers to implement a virtual care service [14]. The subsequent analysis of interviews with patients and providers aimed to understand their experiences with virtual clinical encounters. The study was conducted in northern British Columbia, Canada, in partnership with knowledge users in Northern Health.

The virtual kidney care (Tele-Kidney Care) program [15] is provided through Northern Health, the health authority that delivers health care across the region to 32 communities and 55 First Nations communities. The sparsely populated region covers an area of 617,271 square kilometers—approximately the size of France—with a population of about 300,000 [16]. The kidney care clinic is located in the regional center, a city with a population of 80,000. Virtual care is offered to individuals with predialysis chronic kidney disease and those who have received kidney transplants. Patients attend their local health care facility for virtual appointments and communicate via video with the specialist kidney care staff located in the regional center. Some follow-up communication, particularly during the COVID-19 pandemic, occurred via telephone.

Study participants were 10 providers and 17 patients, all recruited through the kidney care program. Providers (2 men and 8 women) consisted of 8 clinical professionals (a nephrologist, nurses, a dietitian, a pharmacist, and a unit assistant) and 2 information technology specialists. The patients, 6 men and 11 women, were identified by the program’s clinical leader as individuals who had provided feedback on virtual services to the kidney care team. They were contacted by the clinical leader in person or by telephone and provided with both oral and written information about the study. Those who chose to participate then contacted the research coordinator directly or consented for a care provider to pass their contact information to the coordinator, who then reached out to them. Potential participants were given further information, and if they chose to proceed, written consent was obtained. All providers and patients who were approached contacted the researchers and volunteered to be interviewed. None withdrew from the study.

Two senior authors (GM and MM) and a PhD research trainee (SJ) conducted 30- to 60-minute interviews by telephone between November 2020 and February 2021. Questions for providers focused on delivering kidney care virtually and how this changed with COVID-19. Questions for patients focused on their initial experience with virtual care for kidney treatment and how they had experienced virtual care since then. The interview questions for patients and providers are presented as Multimedia Appendices 1 and 2, respectively. All interviews were audio recorded and transcribed.

Hermeneutics is a qualitative research methodology rooted in the philosophical tradition of interpretation. It views human experience as emerging from the interrelations between individuals and their social environments, which are shaped historically over time [17]. Understanding of experience is developed through dialogue, where differing perspectives lead to new insights into a topic of interest. These principles have been operationalized in research using interviews [17] to address complex topics of human interrelationships, which are influenced and shaped by contextual factors. In the case of the renal service, geography and technology had significant impacts on how care was structured, delivered, and perceived. Data analysis in hermeneutic research goes beyond identifying themes from interview transcripts to develop interpretations that deepen the understanding of the topic in relation to transdisciplinary sources, revealing aspects that may be significant for practice. Hermeneutics is a suitable methodology for exploring a topic like virtual care encounters, which are relatively new and complex, and require investigation into their emerging implications for practice.

The research team analyzed the data through a systematic process, working iteratively through several stages of interpretation. These interpretations were compared, contrasted, and refined with insights from relevant literature and materials. Initial analysis was conducted by 6 academically based team members, with interpretations carried out by the full team. The team discussed the interpretations while remaining open to questions and alternative viewpoints. They included substantive quotes to preserve the depth and context of the data, ensuring rigor and allowing readers to assess the relevance of the findings in the context of virtual care encounters beyond the specialty focus of renal care.

Harmonized ethical approval for this study was obtained from the University of Northern British Columbia and Northern Health (REB H20-02263). Informed consent was received from all participants, allowing for interpretive analysis of results beyond the original scope of the implementation study. All interview data were deidentified, with identifying details omitted from the reported data. Quotations were organized by theme, not by association with a particular participant. Each participant received a CAD $25 (US $17.86) gift certificate for a coffee shop chain.

When the research team met to analyze the data, we found that participants had a lot to say about their experiences with in-person encounters compared with virtual encounters, as well as video-link versus telephone encounters. What made the data so rich was that we interviewed patients who had experienced both in-person and virtual appointments at different stages of their kidney illness and treatment, and who saw these encounters change again during the COVID-19 pandemic. Combined with interviews with providers, we gained a comprehensive and varied perspective on clinical encounters related to chronic kidney disease. Through team discussions, we identified 2 broad themes.

The first theme focused on the structure of the encounter in a phenomenological sense—how 2 or more people connected around a specific occasion of health care needs, and the networks of human, technological, and material resources, required by both patients and providers, that were invoked in order for encounters to happen. The second theme focused on the content of the encounters—how relationships were formed, cultivated, or inhibited through different modes of interaction between patients and providers. Crucially, in the health care context, it also examined the role of trust in clinical encounters.

The rationale for adopting virtual care in regions like northern British Columbia is driven by factors such as distance, low population density, and limited availability of specialized health care resources. Patients clearly expressed how virtual care significantly reduced the time and planning required for appointments. One person compared it with having to make a 4-hour drive each way to the central clinic:

For this patient, as for most people, the impact goes beyond distance and travel time. There are ripple effects across family, work, and social networks when having to commit an entire day, or even an overnight stay, to attend a medical appointment. Climate and time of year were additional factors promoting the convenience of virtual visits compared with, “...a five hour drive through the [mountain] pass in the middle of winter often times.” Another efficiency remarkable to patients was the structure of the visit, where they met with different clinical team members in sequence during a single encounter:

Clinicians also recognized the importance of convenience for patients. One nurse observed, “I’m just guessing here, but I would say 95% appreciate the video conference and not having to travel. Like they choose it now.”

Another form of convenience for providers was related to specific role requirements. For example, a pharmacist found that phone call encounters during COVID-19 restrictions were helpful for the discussions she needed to have with patients. As patients were now calling from home, they could easily access all their medications:

One immediately important network for patients, understandably, was their health care providers outside the renal team. Although our focus in the study was the kidney care team, participants frequently mentioned other clinicians in relation to their needs and preferences, often referring to primary care, usually their family physician. For some, there was a very positive link between the kidney care team and primary care. Even if they were unaware of the details, they felt reassured that information flowed easily between the 2 parts of the health care system.

Health care networks looked different for patients with comorbid conditions and more complex needs. One patient described an effective communication network involving the kidney care team, 2 other specialist teams managing a comorbid condition, and the primary care physician:

Another variation in health care networks was seen for peritoneal dialysis patients and providers, where material elements, such as dialysis equipment and the need for hands-on patient education and training, were central. Dialysis care required a network to facilitate the delivery or replacement of supplies, as well as training on when and how these actions were necessary. One patient mentioned that supplies were delivered during COVID-19 restrictions and left on the doorstep. A clinician described nurses in some local communities who “can change transfer sets for us.” One of the nurses spoke about a coordinating role involving the nephrologist, nurses, local pharmacies, and families to ensure the timely delivery of dialysis supplies. She would also check that local nurses had the necessary support to assist dialysis patients. For those involved with dialysis, the introduction of virtual care required additional logistics and resources due to the essential material elements in their networks.

Not all the patients in the study mentioned peer support as part of their network, although one participant did bring it up:

The same participant also mentioned the support he and his family received from the Kidney Foundation of Canada, which provided subsidized accommodation in Vancouver during an intensive treatment period that required him to stay in the city.

People requiring specialty care for kidney conditions maintain ongoing contact with their kidney care team over years or even decades, following a chronic care model. Patients and providers have regular interactions, and when a virtual option was introduced, most patient participants welcomed the change, finding little difference compared with face-to-face encounters. One participant said, “It’s pretty much the same thing said and done as if you were actually sitting in a doctor’s office” and another, “I mean it’s good to meet them in person and talk about your problems...but no, the video conference filled that gap really easily.” While they acknowledged a difference, participants in our study did not place much value on it: “I guess it’s a little bit nice seeing a person’s face and everything but either way it doesn’t bother me too much.”

This contrasts with the trade-off of not having to travel, as mentioned earlier.

For some providers, by contrast, the loss of face-to-face encounters was seen as eliminating an essential aspect of care. One physician described the trade-off this way:

Virtual visits were intended to replace in-person visits, and one provider involved with the technical side of implementation stated, “we pretty much follow the same template as if we’re doing in-person care.” However, a provider in a clinical management role identified a hierarchy of preference: “...The face-to-face visits are much more important and sometimes the video conference, it’s almost like a touch-base in between.”

The idea that video or phone encounters are substandard compared with face-to-face visits might be reinforced or complicated by other changes that came with switching to video encounters. One practitioner noted a change in the duration of visits: “...[N]ormally I would see a client for at least 30 minutes, if not maybe 45 minutes...virtually it’s more like 15 minutes.”

Both patient and clinician participants pointed out a correlation between the stability of illness and the need for in-person encounters. In other words, if a patient’s condition became unstable with concerning symptoms or entered a new phase of treatment, such as dialysis, in-person communication became much more important. It should be noted that this flexibility was already built into the kidney program’s practices.

A dietitian commented that video images of faces omitted a lot of visual information she would typically observe if seeing a patient in person:

One nurse pointed out a less obvious distinction between video and “face-to-face” contact: “Video versus face to face doesn’t change bad news and responses...[but] I just think they’re going to hear it better [face to face].”

The innovation of the initial virtual kidney care project allowed patients to connect via video from a room in a health care facility in their home community. However, when public health orders related to COVID-19 restricted hospital visitations, all virtual appointments were conducted by phone for the first time. In this context, both patient and provider participants expressed a preference for video over phone visits. One patient commented, “...You get all the information but it’s so much easier to actually see the person talking to you” and another said, “I think just as humans we like to see each other. So much of our communication is visual.” Providers noted that the visual element helped them gather more information about patients. One nurse who followed transplant patients explained, “...When I see their face I remember their case better than if I’m just talking to them on the phone.” A dialysis nurse added, “...I would say on the phone is even worse because you can’t judge their reaction.”

Virtual visits change many of the ways providers and patients are accustomed to interacting in an encounter, and the loss of sensory data during phone visits led to feelings of discomfort or awkwardness for team members, especially when trying to hit the right conversational tone or (re)establish a relational connection. One nurse noted the shift:

As we explored with participants the differences in experiencing virtual encounters, we found that patient participants did not report feeling disconnected or that the encounters were impersonal. Instead, patients consistently described how much they valued the team’s availability, their willingness to accommodate patient needs, and how approachable they were. Patients reported still feeling heard by the team and being seen as individuals. One said, “They give me their full attention every time we’re on the video screen and they seem genuinely interested in what’s going on with me. I haven’t seen it go the wrong way as far as the quality of care” and another, “They’re interested in what you’re doing, and they ask about more than just technical information.”

The patient participants described a sense of trust in the clinical team, where multiple individuals showed interest in their health, symptoms, and personhood, both in person and virtually. The patient participants described comprehensive care experiences that extended beyond the virtual encounter and seemed to view the team as a cohesive unit. By contrast, providers described a more significant shift in their experience of the encounter and how it impacted their one-on-one interactions with patients when conducting visits virtually rather than in person. One physician put it that,

In this study, however, patients described trusting the team and knowing they could rely more or less on the team’s resources depending on the trajectory and severity of their condition. One patient, for example, said “...a quarterly touch base or anybody who will respond to an email in between is fine with me. I’ve become less dependent on them; I don’t feel quite so terrified anymore. I’ve adapted to my life.” Another participant described how reassuring it was to know that the team would advocate for their care if needed.

This team already had an existing interdisciplinary approach to supporting patients before implementing virtual encounters. For example, there is a “reach-in” mechanism where patients can phone a team member or email a provider with a question without needing to make an appointment. Patients expressed how much they valued knowing they could access the team when needed: “...if I ever have any questions that I need to ask them directly, I can phone the clinic and they will either find out themselves or talk to the doctor and get back to me within a day at the latest.” This enabled them to take initiative in their own care: “...it’s good to have the opportunity to...instead of having to make an appointment and waiting to speak to somebody, you can actually just call.”

A second critical factor in patients’ successful acceptance of virtual visits was the preexisting relationship they had with the kidney care team. Patients acknowledged that they felt comfortable during virtual visits because they already knew the team through face-to-face encounters.

Another participant reflected on the value of in-person encounters, saying, “It was a great opportunity to actually talk to them face to face so that now when I talk to them on the phone I kind of know who I’m talking to.”

However, a physician expressed that from the team’s perspective, new patients who had not experienced in-person visits might not feel the same sense of connection:

Knowing patients is vital for providers, as it influences how they plan care, including follow-up or monitoring of patient conditions. It was notable that clinicians working with peritoneal dialysis patients were particularly concerned with enabling patients to use equipment to manage their dialysis at home. This raised broader implications about understanding each patient’s unique circumstances and needs:

A nurse working with dialysis patients also highlighted the importance of bodily presence and materials in providing care, especially when patients needed to learn hands-on skills for the correct use of equipment at home. One nurse described teaching patients about peritoneal dialysis using a dummy:

This nurse believed that the time spent teaching skills also provided valuable insights into understanding a patient’s circumstances:

Providers in this study recognized that achieving lasting satisfaction with virtual encounters may require learning new skills beyond those typically addressed in standard guidelines for virtual care. Provider job satisfaction is an important factor that contributes to the quality of care [18]. One physician noted, “All these little cues of reassurance and compassion, it’s harder. Because we see a face, we don’t see a person...I don’t have the same level of gratification with virtual appointments.” Providers identified the need to find ways to ensure their assessments were both complete and genuine. One nurse stated:

A physician also expressed concern about the sense of incompleteness compared with in-person care, framing this as an ongoing challenge in adapting to virtual care: