Misaligned Metrics: How Performance Measurement Frameworks Constrain Telehealth in Free and Charitable Clinics

Background Free and charitable clinics (FCCs) play a critical role in delivering healthcare services to uninsured and underinsured populations. Although telehealth has the potential to expand access to care in resource-constrained settings, FCCs face operational and reporting demands that may complicate long-term telehealth integration. This study explored how clinic leaders perceived quality measurement and reporting expectations as influencing telehealth implementation and sustainability. Methods An interdisciplinary research team conducted 13 semi-structured key informant interviews with leaders from North Carolina free and charitable clinics. Interviews were conducted as part of a broader study examining telehealth implementation during the COVID-19 pandemic using the Consolidated Framework for Implementation Research (CFIR). Audio-recorded interviews were transcribed and analyzed in MaxQDA 22.0 using thematic qualitative analysis informed by CFIR constructs. Reporting followed Guidance for Publishing Qualitative Research in Informatics recommendations. Results Participants consistently identified performance measurement expectations as a significant challenge affecting telehealth utilization. Clinic leaders described difficulties reconciling traditional quality metrics, many of which rely on in-person assessment and documentation, with virtual models of care delivery. While participants emphasized the importance of accountability, quality improvement, and outcomes reporting, many perceived existing measurement frameworks as insufficiently adaptable to telehealth workflows. These concerns were discussed across all interviews and emerged as a prominent implementation barrier affecting sustainability and long-term integration. Discussion Findings suggest that existing performance measurement structures may unintentionally constrain telehealth adoption in free and charitable clinic settings. Current quality reporting expectations may not adequately account for the operational realities or clinical strengths of telehealth-based care delivery in resource-limited environments. Conclusions To support sustainable telehealth integration in FCCs, policymakers, funders, and accrediting organizations should consider developing more flexible quality measurement approaches that better align with hybrid and virtual care models. Future research should focus on telehealth-specific performance indicators and alternative data collection strategies appropriate for safety-net clinical settings.