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Background: Electronic health records are now the norm in US healthcare. Bidirectional patient portals allow frequent communication between patients and their healthcare team. Many studies have examined the importance of patient engagement and trust between patients and their healthcare team, typically in the context of face-to-face interactions. Little is known about how patient trust and engagement are built or enhanced through electronic communications. COVID-19 provided a unique time in history for this novel exploration. Objective: Our objective was to learn how patients experience trust formation through electronic communication (patient messaging and video visits) with their healthcare team. Design: Our research was guided by grounded theory methodology. Qualitative interviews were conducted between February and December 2020 with patients or their caregivers from an internal medicine clinic in Colorado. Participants: Fifty-one participants were recruited by age group and gender to represent the clinic's adult ambulatory care demographics. Seven were patients' caregivers who were purposefully recruited. Average age was 53 with an educated, middle class, and largely white predominance in our eventual sample. Approach: Thirty-minute semi-structured interviews were conducted using an interview guide informed by a validated physician-patient trust scale. Interviews were conducted by telephone, recorded via Zoom, and transcribed. Results were analyzed and coded in ATLAS.ti utilizing the constant comparative method, with two coders. Key Results: Patients experienced enhanced trust in their healthcare team through electronic communications. Interpersonal and system factors contributed to trust formation. Promptness of reply was the most salient factor in trust formation with a majority desiring same day response. Conclusions: Patients now rely on electronic communication with their healthcare team. Opportunities exist to leverage this to improve health outcomes. Important research in expanded demographic groups, along with ambulatory healthcare redesign, will be necessary to optimize benefits of electronic communication with patients and meet patient expectations. [ABSTRACT FROM AUTHOR]