Rodgers’ evolutionary concept analysis method was used to guide the development of the concept of TRC in telehealth [19]. Conducting a concept analysis through Rodgers’ guidelines includes identifying the concept, alternative terms, and appropriate methods for data collection; collecting data to identify attributes, antecedents, and consequences; and providing an example and finding areas for further development of the concept [20]. In this method, attributes refer to the cluster of characteristics comprising the definition of the concept. Antecedents are events that have been associated with the concept, and consequences are what happens as a result of the concept. Rodgers’ evolutionary concept analysis method acknowledges that concepts shift over time, influenced by use, application, and significance, resulting in an analysis that is practice-related and current [21]. Concept analysis is a key component of knowledge base development and enables systematic and cohesive understanding of the concept being investigated [22]. It is through understanding the conceptual development and current state of the science related to the concept of TRC in telehealth that we can link conceptual work to solution-based scholarship.

An integrative review strategy as outlined by Whittemore and Knafl [23] was used to methodically search the existing literature on phenomenon related to TRC in telehealth. PubMed, Embase, PsycINFO, and CINAHL were used to search for publications. The keywords used were “patient provider relationship,” “physician patient relation,” “nurse patient relations,” “patient provider connection,” “connectedness,” “provider rapport,” “nurse-patient relations,” “telehealth,” “telemedicine,” “remote,” “virtual,” and “virtual visits.” The initial search resulted in 2763 papers. Rayyan software (Rayyan Systems, Inc) was used to systematically review papers through a blinded collaborator methodology. The inclusion and exclusion criteria can be found in Textbox 1.

Each title was reviewed to identify papers that reflected the concept of TRC, and papers were excluded that did not meet these criteria. Next, the remaining abstracts were reviewed to determine if inclusion criteria were met. Papers meeting inclusion criteria were read in their entirety, and those that did not reflect the concept of TRC in telehealth were excluded. As the final step for paper inclusion, collaborators were unblinded, and any conflicts around inclusion or exclusion of papers were resolved through open discussion. In total, 13 papers were included in the final concept analysis (Figure 1).

In total, 9 papers described studies using qualitative methodology [13-15,24-29], and 4 were systematic or literature reviews [12,30-32]. The modes of telehealth used in these papers include videoconferencing [12-15,24-32], using audio only (over the telephone or internet) [12,14,15,28,31], text-based messaging [12,14,28,29,31], asynchronous messaging (video or audio) [12,14,26-28,31], and remote data management [12,14,15,26-28,31].

There is currently no standard definition of TRC in telehealth and the literature references several different terms for this phenomenon. In total, 10 of the 13 papers reviewed identified the importance of patient-provider relationships in understanding connection or alliance. Terms used to refer to the concept of TRC in the reviewed papers were doctor-patient relationship [27,29], patient-provider relationship [13-15], doctor-patient interaction [12,31], and nurse-patient relationship [24]. Connection was identified as a therapeutic relationship or alliance [15,30,32], connection [25,26], rapport [13], closeness [31], socioemotional communication [29], and empathic communication or affective expression [14]. The term presence, defined by Tuxbury [28] as the reciprocal flow of openness, and dialog was used as a surrogate for TRC and was described in 3 papers [24,28,30] (Table 1).

Included papers were reviewed to determine the attributes, antecedents, and consequences of TRC in telehealth. Table 2 summarizes each paper’s contribution to the conceptual elements of TRC in telehealth.

The defining attributes of TRC in this concept analysis were identified as “provider ability to evaluate patient concerns,” “interpersonal communication skills,” “knowledge of patient community and culture,” “mutual trust and respect,” “presence,” “bidirectional responsiveness,” “empathy,” and “relationship.” Each of these attributes will be further described in detail.

Antecedents are the events that need to be present prior to the development of TRC [21]. In this analysis, antecedents were categorized as confidence in clinical abilities, suitable environment, and knowledge of community.

TRC is associated with several positive outcomes. An overarching consequence is that TRC improves the quantity and quality of patient-provider communication, which increases mutual respect and caring, benefiting both providers and patients. TRC allows providers to obtain quality information from patients, resulting in improved well-being and a sense of purpose. For patients, TRC results in an increased commitment to follow-up [26,28], feeling emotionally supported [2], and an increased ability to cope [26,28]. For both providers and patients, there is an alliance [24,25,31,32], improved communication (quantity and quality) [14,28-31], mutual respect and caring [25,29], enhanced relationship [14,24,29,31,32], promotes long-term partnership [14,24,30], collaborative decision-making [31,32], greater satisfaction with care [29], patient and provider more at ease [24,25,30], empathy [2,14,24,32], more accurate diagnosis of problems [14,31], and being present [24,31,32]. For patients, there is improved follow-up care [9,15], feeling emotionally supported [15,25,28,29,31], improved health outcomes [9,15,31], improved adherence to treatment plan [9,31], patient satisfaction [15,28], feeling heard and understood [15,25,28,30], and empowerment [15,25]. Providers gain a sense of well-being and sense of purpose [1,14,24,28], improved assessment of the patient [1,14,29], increased familiarity with patients [28,31], and understanding of patient concerns [1,14,29,31] (Figure 2).

Empirical referents are ways in which we see TRC demonstrated in telehealth. One example of how this concept is demonstrated was by Hiratsuka et al [26] who found that when providers engaged with Alaska Native and Native Hawaiian people recognized language barriers and took the time to make sure that the information was understood, patients felt more comfortable with the providers’ willingness to listen and showed them respect and caring. Botrugno [12] gave examples of how the behaviors of providers and patients during consultation can create TRC. When patients feel more in control and there is more expression of emotions and discourse between patient and provider, the result is adherence to treatment plans of care and improved health outcomes. Barrett [24] described therapeutic presence as offering comfort and reassurance to patients through “being with the patient” and taking the time to make them comfortable; “they’re pleased to see you, often quite reassured, they like to hear your voice, see your expression” [24]. When patients have affective expressions and providers have empathic responses, TRC is established, more information is obtained leading to long-term partnership and better health outcomes [14]. Awareness of verbal and nonverbal communication conveys empathy and increases rapport; this can be done with a simple wave of hello to put the patient at ease [25]. To better illustrate the application of TRC in clinical practice, the following patient exemplar is presented.

Andrea Marshall (pseudonym) is a young adult with a diagnosis of multiple sclerosis (MS). She lives in a rural community where she does not have access to a neurology provider specializing in MS. She has been referred to a clinic hundreds of miles away but will need to have a telehealth visit to establish care. Andrea Marshall has been prescribed a disease-modifying therapy from a local provider, but she has not been adherent with taking this medication. During her first videoconferencing visit with the MS specialist, the provider initiates the visit by introducing themselves and explaining how the visit will proceed. The provider ensures that the environment is suitable by talking with Andrea Marshall about lighting, placement of the camera, and decreasing distractions. The provider then takes time to find out more about Andrea Marshall. They have a casual conversation about her likes and dislikes, and the provider uses humor to put her at ease. During the visit, the provider learns the patient lives in a community where there is mistrust in health care providers and general disbelief in modern medicine. The provider takes the time to discuss the patient’s values and preferences around taking the disease-modifying therapy for her MS. The patient is interested in taking the medication, and both parties strategize how the patient may adhere to the prescribed regimen without feeling ostracized from the community. Throughout the visit, the provider carefully maintains eye contact and is intentional about their use of body language to convey empathy. This behavior allows the patient to feel comfortable, and they ask several questions. The provider conducts their telehealth examination and demonstrates competency by explaining what they are doing and why. The provider takes time to provide education on the new medication and the importance of close follow-up. The provider uses active listening throughout the visit. At the end of the visit, the provider ensures that all of the patient’s questions have been answered, and they schedule a follow-up meeting via videoconferencing in 2 weeks to review the treatment plan. The patient thanks the provider for their time and follows up after 2 weeks.

TRC is a novel concept. Although we have appreciated the importance of patient-provider connection in the past, little attention has been paid to the intentionality of TRC in the setting of telehealth. Intentionally creating a mutually beneficial relationship using telehealth platforms goes beyond what we currently think of as web-side manner or telepresence. Those concepts do not address the intentionality or bidirectional nature of patient-provider relationships affecting patient-centered outcomes. Recognizing that skills needed to establish TRC via telehealth are unique from those used during in-person visits allows providers to make necessary adjustments to their clinical approach. This concept allows us to better understand what skills are needed to achieve TRC in telehealth. TRC is the experience of a mutually responsive patient-provider relationship that is built on mutual respect and understanding. Based on the findings of this concept analysis, the proposed definition of TRC is the intentional use of relationship connection between health care providers and their patients toward a therapeutic aim.

Prior to the establishment of TRC, both providers and patients need to be comfortable with and confident in providing and receiving health care via telehealth. There continues to be hesitancy among both groups as providers often fear missing important clinical information [26] and patients are concerned their providers may miss important information as providers are often less attentive during telehealth visits [13]. Currently, there are no practice standards for training health care providers in telehealth, which may contribute to the lack of confidence using these platforms. Patients need to be assured they will receive the same care via telehealth that they would in-person, and providers can play a significant role in making their patients feel comfortable. Providers should be trained in performing physical examinations and taking clinical histories via telehealth to increase their confidence. Comfort for the patient can additionally be increased by ensuring the environment is conducive to a clinical visit. This should include a plan to address issues with technology and a way to minimize distractions and promote privacy. One example of how to establish trust via telehealth is to explicitly discuss issues concerning patient privacy [32]. Based on the concept analysis presented in this paper, there are many skills providers can adopt to improve the telehealth experience for both them and their patients.

Communication needs to be a central focus of establishing TRC in telehealth. It has been noted that conversations between patients and providers via telehealth are often dominated by physicians with less small talk and overall shorter visit length [31]. Providers need to be trained on the skills needed to successfully communicate with patients via telehealth platforms. This training should include enhanced interpersonal communication by verbally reflecting on what the patient is saying to improve the conversation [25]. Additionally, providers need to ensure their communication includes not only information but also emotion, which can help demonstrate empathy [12]. One example is responding to a patient fluidly without unnecessary breaks or pauses in the conversation helps to reinforce the demonstration of empathy [32]. Being empathetic in responses resulted in greater patient satisfaction and improved problem-solving [14,26]. During in-person visits, delayed pauses during conversation are more natural as you can interpret body language. During telehealth interactions, delayed responses, lack of initiative, lack of emotional comfort, and being unfriendly lead to patient dissatisfaction with the visit [29]. Patients want to feel that their provider is present, which is often more difficult to establish when both parties are not in the same physical space.

To establish presence, nonverbal communication is important [25,26]. When eye contact was lacking, patients reported feeling unheard and neglected by their providers [13]. Approach to communication differs depending on the type of telehealth platform. While eye contact has been demonstrated to help control communication [30], it is not an option for telehealth platforms that are asynchronous. In these situations, communication needs to convey essential elements of the relationship. Telehealth has significant potential to strengthen the bond between providers and their patients. Telehealth has been shown to provide a method for providing emotional support resulting in a deeper understanding of patients’ emotions and perceptions [27]; however, providers need more training as they perceive rapport to be lower when using telehealth [32]. Clinical presence might be inhibited by lack of touch [24]. One way to overcome this barrier is to increase the frequency of visits [24]. Innovative telehealth practices should consider the frequency of visits as it may compensate for the lack of in-person touch. Presence is reciprocal, and both patient and provider must choose to work toward a shared goal [28].

A crucial goal of TRC is working together toward achieving a therapeutic aim. Trust is necessary for patients to work toward common goals established between themselves and their providers; however, this often requires touch during in-person visits [30]. Without in-person touch, establishing trust requires more interactions over telehealth, and it takes longer to establish when compared to in-person visits [30]. This provides additional support for the need for more frequent telehealth interactions.

Bidirectional responsiveness is important to the development of TRC as both parties need to be invested and working toward the same outcomes. The bidirectional aspect of relationships evolves over the course of treatment [32]. Relationships were more difficult to establish via telehealth if the patient and provider did not have a prior relationship as small talk was found to be more difficult to initiate [13]. Providers need to approach new patients with more time realizing that it is more difficult to establish TRC with new patients when using telehealth.

Understanding TRC within the conceptual framework of relational cultural theory allows researchers and providers to design and implement strategies for training providers in the use of telehealth from a unique perspective. Future research should consider telehealth as a modality to improve TRC in vulnerable populations. Patient populations who rely on technology or those who cannot regularly access clinic visits in person could greatly benefit from developing relationships with their providers in a remote setting. Evidence demonstrates the benefit of TRC; however, we need to better establish practice guidelines for considering the intentional application of TRC in practice. There are countless opportunities to address disparities and improve equity by incorporating the intentionality of TRC in telehealth platforms.

There are several limitations to the methodology used in this concept analysis. As this paper aimed to explore a new concept, the search strategy may have unintentionally excluded additional terms that are associated with the elements of TRC. There was no empirical evidence to support our findings. Each of the papers reviewed in this paper was systematic review or used qualitative methodology. Telehealth platforms have only recently emerged as a widespread modality for medical appointments so the search strategy resulted in limited data regarding TRC in telehealth.

Patient-provider connection and relationships have long been acknowledged as an important aspect of patient care. Past research on connection has explored connectedness and therapeutic relationships, but there has been limited exploration of how TRC is found and fostered in telehealth. This analysis supplies a preliminary theoretical framework of TRC. This framework will be useful in developing tools to measure TRC as well as evaluate and educate providers on how to improve their ability to connect to patients during telehealth appointments.

This analysis aimed to clarify the concept of TRC in telehealth. Telehealth necessitates alternative modes of connection and relationship development as compared to in-person clinic visits. With the rapid expansion of telehealth platforms, there is a need to provide a clear conceptualization of TRC in telehealth in order to establish best practices for health care providers. This work will enable the development of guidelines and educational interventions aimed at improving TRC in telehealth and guiding future research with the goal of optimizing patient-centered outcomes.