The pandemic made telemedicine an instant hit. Patients and providers feel the growing pains.

Crystal Joseph pays for two telemedicine video services to ensure that her small therapy practice in Silver Spring, Maryland, can always connect with its clients.

She's been burned before. During one hours-long service outage of SimplePractice in late May, PsycYourMind, which offers mental health counseling and group sessions for Black patients, lost about $600 because of missed appointments. Livid, Joseph requested a small credit from the telemedicine service, which costs $432 monthly for her team of clinicians and trainees. SimplePractice refused, she said.

"What they offer is phenomenal, especially being founded by a therapist," said Joseph, a licensed clinical professional counselor. "But with a private practice, if you don't get paid, you don't eat." For some sessions, she was able to hop onto her backup, VSee, which costs her $49 each month. Some of her peers use Zoom. But even though Joseph keeps links to both her SimplePractice and VSee accounts in her email signature, a last-minute switch-up can feel messy for clients, and she never charges a no-show fee when it's an "act of God."

Major health systems, clinics and private practices alike pivoted swiftly to telemedicine when the covid-19 pandemic forced the nation to shelter in place and patients could no longer safely venture into health care settings. But the video services were not equally prepared for the titanic influx in users, said Kapil Chalil Madathil, an engineering professor at Clemson University who has researched how easy — or difficult — telemedicine platforms are to use.

Videoconferencing vendors, including Zoom, tech giants like Microsoft and Cisco, and a host of telemedicine startups absorbed an explosion of demand over the past pandemic months. PitchBook estimates that revenue from the global telehealth market will hit $312.3 billion in 2026, up from $65.5 billion in 2019. But beyond connectivity issues, some services seemed designed for dissatisfaction. They required patients to download a desktop application or made them click through multiple steps to log in. "On an iPhone, I can click one button to see my grandkids," Madathil said. "Can we not make telemedicine systems as easy as that?"

Providers often were locked in with telemedicine options from services they were already using — or what they could afford. Joseph was already paying SimplePractice to house her practice's electronic health records, so moving to another platform would have been time-consuming and costly, she said.

Practitioners have depended on telemedicine to keep their businesses afloat in the pandemic, and Joseph plans to keep a portion of her sessions virtual. A one-stop shop for private practice clinicians, SimplePractice offers scheduling, an electronic medical records system and insurance claims filing along with its video services. The company said it hosted 17 million telehealth appointments last year.

"The expectations are rising," said Diana Stepner, a SimplePractice vice president. "Individuals want screen sharing, they want grid views, so we've added new capabilities since the pandemic began and will continue to do so."

Zoom became an overnight poster child for staying connected as employees in every line of business across the country worked from home. Its revenue jumped 326% in the fiscal year that ended on Jan. 31, 2021, over the previous year's. Even before the pandemic, the Silicon Valley company offered a service tailored for health care practitioners that complied with the Health Insurance Portability and Accountability Act, which protects patient privacy, and could be synced with Epic Systems electronic medical records.

"It was 'all bets are off' once the pandemic hit," said Heidi West, who heads the health care division at Zoom. West pointed to the CARES Act and the loosening of telehealth regulations, which allowed doctors to be reimbursed for telemedicine at the same rate as for in-office visits.

UCSF Health, which had contracted with Zoom for virtual visits since 2016, gave every doctor and clinician a personal link for its videoconference line and a separate virtual waiting room. Telemedicine calls for outpatient care within the San Francisco academic medical system spiked from 2% of visits in February 2020 to more than 60% by that April. Doctors were seeing patients — who often used their cellphones — in their homes, in parked cars and in one case on skyscraper scaffolding, where a construction worker stepped away for a quick doctor's visit, said Linda Branagan, director of telehealth at UCSF Health.

Zoom is not immune to glitches, Branagan said, but it seems to bounce back faster than many other vendors and "recovers quite gracefully."

UCSF surveyed its patients and found they were more satisfied with their video visits than their in-person ones. More than a year later, almost one-third of outpatient visits are still conducted virtually.

Elsewhere, the initial transition was rockier. Dr. James McElligott, who runs Medical University of South Carolina's Center for Telehealth, said the hospital could not afford to upgrade its Vidyo conferencing system, so he opted for Doxy.me, which the center already used for research and had an easy-to-use interface.

"We were able to get clever, and many doctors really liked it," McElligott said. The software has a waiting room from which patients can be transferred into virtual rooms with providers. The health system sent patients a text with a direct link for their appointments so that they didn't lose time.

"But we couldn't control quality or solve connectivity issues ourselves," he said. "We did have a lot of patients who, despite it just being a link, were uncomfortable waiting." That led to some patients abandoning visits, he added.

Doxy.me employed just eight people when the video telemedicine service saw an unwieldy increase in users in March 2020. For two weeks straight, the company signed up 20,000 new health care providers a day, said founder and CEO Brandon Welch, amassing a backlog of customer service inquiries. One day, Welch recalled, there was a 30-second queue for the website to load because so many people were logging on simultaneously.

"We hired anyone who could walk and chew gum at the same time," joked Welch, noting that many of those early pandemic hires, largely tackling customer service, had been recently laid off from other industries, like restaurants.

Doxy.me automated the sign-up process as quickly as possible. The service ballooned from 80,000 users to 850,000 as it assembled a team of 120 employees. And it is still hiring. Doctors and clinicians can sign up for the basic HIPAA-compliant service — which includes audio, video and a patient waiting room — at no charge. But for enhanced options, like screen sharing or shared rooms, there's a price tag of at least $29 a month.

For many doctors and clinicians, the move to virtual visits may be permanent, even with all the technical hiccups. A survey conducted by SimplePractice of over 2,400 clinicians in February found that 88% expected to continue offering a telehealth option.

Jessica Ehrman, a Santa Monica, California, therapist who plans to keep her practice fully remote, finds telemedicine much easier for scheduling, particularly for kids who have short windows of availability. Still, connectivity issues during that small time frame can tarnish the whole session.

"If you're talking about deep childhood trauma — having your connection time out then? It's really frustrating when we're paying for a service," said Ehrman, who has been suddenly dropped from sessions, experienced lags and even once saw back-end coding pop up in her provider portal. Like Joseph in Maryland, she uses SimplePractice through her agency and personally pays for Zoom's HIPAA-compliant option to head off technical difficulties.

Despite the problems, few health care providers want to forsake the technology. "Video visits are cemented," said Branagan. "I will never again have to have a conversation with a physician to convince them that you can do health care via video."