Contents lists available at ScienceDirect International Journal of Medical Informatics journal homepage: www.elsevier.com/locate/ijmedinf Exploring how virtual primary care visits afect patient burden of treatment L.T. Kelley a , M. Phung a , V. Stamenova a , J. Fujioka a , P. Agarwal a , N. Onabajo a , I. Wong a , M. Nguyen a,c , R.S. Bhatia a,d , O. Bhattacharyya a,b, * a Women’s College Hospital Institute for Health System Solutions and Virtual Care (WIHV), 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada b Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada c Department of Health Sciences, University of Toronto, Toronto, Ontario, Canada d Department of Medicine, University of Toronto, Toronto, ON, Canada ARTICLE INFO Keywords: Patient burden Patient experience Digital health Virtual visits Primary care ABSTRACT Background: There is growing emphasis on the role of digital solutions in supporting chronic disease manage- ment. This has the potential to increase the burden patients experience in managing their health by ofoading care from the health system to patients. This paper explores the efects of virtual visits on patient burden using an explicit framework measuring both the work patients do to care for their health and the challenges they experience that exacerbate burden. Methods: This mixed methods study evaluates a large pilot implementation of virtual visits (video, audio, and asynchronous messaging with providers) in primary care in Ontario, Canada. Participants were recruited using convenience sampling from patients using a virtual visit platform to complete a semi-structured interview or a survey including a free-text response. We conducted 17 interviews and reviewed 427 free text responses related to explore patients' perceived value and burden of these visits. We used qualitative analyses to map patients’ feedback on their experience to the framework on patient burden. Main findings: Virtual visits appear to reduce the work patients must do to manage their care by 1) improving access, convenience, and time needed for medical appointments, and 2) making it easier to access information and support for chronic disease management. Virtual visits also alleviate patients' perceived burden by im- proving continuity of care, experience of care, and providing some cost savings. Conclusions: Virtual visits reduced overall patient burden of treatment by decreasing the required patient efort of managing medical appointments and monitoring their health, and by minimizing challenges experienced when accessing care. For regions that want to improve patient experience of care, virtual visits are likely to be of beneft. There is need for further research on the generalizability of the fndings herein, particularly for high- needs populations under-represented such as those of low socioeconomic status and those in rural and remote locations. 1. Background The prevalence of chronic disease is growing, increasing demand on health systems globally [1]. This strain manifests among primary care providers, who serve an essential role in supporting these patients [2,3]. Increased demand for primary care has contributed to challenges in accessing services in a timely fashion, not only for patients with chronic diseases, but also for patients’ general health concerns and maintenance [4]. Given fxed resources, health systems often respond to the growing burden on primary care by ofoading care management to patients (and caregivers) without enhancing their capacity to manage their conditions [5,6]. This increases the burden on patients who both experience and manage their disease, and can lead to poor health outcomes [5]. Virtual visits have been proposed as a cost-efective mechanism to increase access to primary care and improve chronic disease manage- ment through methods such as continuous monitoring and promoting behavioural changes [7–10]. Further, virtual visits can support patients in medication management, health monitoring, organizing medical appointments and lab tests, and communicating medical information; all of which contribute to patient burden [11–13]. They can also reduce travel and automate disease monitoring through wearables [14–16]. However, to avoid increasing patient burden, technology-enabled care models must be designed around patients’ needs [17–19]. Digital https://doi.org/10.1016/j.ijmedinf.2020.104228 Received 26 September 2019; Received in revised form 20 June 2020; Accepted 27 June 2020 ⁎ Corresponding author. E-mail address: onil.bhattacharyya@wchospital.ca (O. Bhattacharyya). International Journal of Medical Informatics 141 (2020) 104228 1386-5056/ © 2020 Elsevier B.V. All rights reserved. T