Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Using video consultations to support family carers of people living with dementia

Established in 2019, the Lincolnshire Admiral Nurse Service supports family carers of people living with dementia through psychosocial interventions. Before the coronavirus disease 2019 (COVID-19) pandemic, the team provided home visits as standard, but the fact that Lincolnshire is a large rural county affected the team's ability to provide timely support to all the carers who needed it. In 2019-20, a practice development project underpinned by participatory action research was undertaken to trial the use of video consultations with carers. However, carers' uptake of video consultations was low and the project was affected by the COVID-19 pandemic. This article describes the project and discusses the findings of its evaluation. The Admiral Nurse team had mixed experiences and felt that, overall, its support was more effective when delivered face to face. The project provides insights into the challenges and benefits of video consultations for delivering psychosocial interventions to carers of people living with dementia.

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images), relationally (interpersonal interactions are altered), and clinically (patients are unique, some examinations require contact, and clinicians have deeply-held habits, dispositions and norms). Many of these challenges have an under-examined ethical dimension. In this paper, we present a novel framework, Planning and Evaluating Remote Consultation Services (PERCS), built from a literature review and ongoing research. PERCS has 7 domains-the reason for consulting, the patient, the clinical relationship, the home and family, technologies, staff, the healthcare organization, and the wider system-and considers how these domains interact and evolve over time as a complex system. It focuses attention on the organization's digital maturity and digital inclusion efforts. We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards. In contrast, our empirical data reveal that strategic decisions about establishing remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely are fraught with contradictions and tensions-for example, between demand management and patient choice-leading to both large- and small-scale ethical dilemmas for managers, support staff, and clinicians. These dilemmas cannot be resolved by standard operating procedures or algorithms. Rather, they must be managed by attending to here-and-now practicalities and emergent narratives, drawing on guiding principles applied with contextual judgement. We complement the PERCS framework with a set of principles for informing its application in practice, including education of professionals and patients.

Fifteen-minute consultation: A practical approach to remote consultations for paediatric patients during the COVID-19 pandemic

OBJECTIVE

This practical approach to the use of telehealth aims to offer clinicians a framework for video and telephone interactions with children and families accessing healthcare.

DESIGN

Using a standardised case to illustrate how video and telephone consultations can be used during the COVID-19 pandemic.

SETTING

The emergence of 2019 novel coronavirus (COVID-19) is having a massive impact on society. Routine face-to-face consultations were reduced to reduce potential spread of the virus. Clinicians still need to provide ongoing safe care, particularly for more complex patients. Telehealth is the delivery of healthcare services across geographical barriers using information and communication technologies to improve health outcomes.

INTERVENTION

In this article, we describe a 'How to' approach to using virtual consultations based on our experience and a review of expert guidelines.

CONCLUSION

Virtual consultations can be more convenient and have the potential to improve access for patients. Many have embraced these technologies for the first time during this pandemic.

Family and health-care professionals managing medicines for patients with serious and terminal illness at home: a qualitative study

Background

More effective ways of managing symptoms of chronic and terminal illness enable patients to be cared for, and to die, at home. This requires patients and family caregivers to manage complex medicines regimens, including powerful painkillers that can have serious side effects. Little is known about how patients and family caregivers manage the physical and emotional work of managing medicines in the home or the support that they receive from health-care professionals and services.

Objective

To investigate how patients with serious and terminal illness, their family caregivers and the health-care professionals manage complex medication regimens and routines of care in the domestic setting.

Design

A qualitative study involving (1) semistructured interviews and group discussions with 40 health-care professionals and 21 bereaved family caregivers, (2) 20 patient case studies with up to 4 months’ follow-up and (3) two end-of-project stakeholder workshops.

Setting

This took place in Nottinghamshire and Leicestershire, UK.

Results

As patients’ health deteriorated, family caregivers assumed the role of a care co-ordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals. Access to support, resilience and coping capacity are mediated through the resources available to patients, through the relationships that they have with people in their personal and professional networks, and, beyond that, through the wider connections – or disconnections – that these links have with others. Health-care professionals often lacked understanding of the practical and emotional challenges involved. All participants experienced difficulties in communication and organisation within a health-care system that they felt was complicated and poorly co-ordinated. Having a key health professional to support and guide patients and family caregivers through the system was important to a good experience of care.

Limitations

The study achieved diversity in the recruitment of patients, with different characteristics relating to the type of illness and socioeconomic circumstances. However, recruitment of participants from ethnically diverse and disadvantaged or hard-to-reach populations was particularly challenging, and we were unable to include as many participants from these groups as had been originally planned.

Conclusions

The study identified two key and inter-related areas in which patient and family caregiver experience of managing medicines at home in end-of-life care could be improved: (1) reducing work and responsibility for medicines management and (2) improving co-ordination and communication in health care. It is important to be mindful of the need for transparency and open discussion about the extent to which patients and family caregivers can and should be co-opted as proto-professionals in the technically and emotionally demanding tasks of managing medicines at the end of life.

Future work

Priorities for future research include investigating how allocated key professionals could integrate and co-ordinate care and optimise medicines management; the role of domiciliary home care workers in supporting medicines management in end-of-life care; patient and family perspectives and understanding of anticipatory prescribing and their preferences for involvement in decision-making; the experience of medicines management in terminal illness among minority, disadvantaged and hard-to-reach patient groups; and barriers to and facilitators of increased involvement of community pharmacists in palliative and end-of-life care.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.

The Effect of 24/7, Digital-First, NHS Primary Care on Acute Hospital Spending: Retrospective Observational Analysis

BACKGROUND

Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective.

OBJECTIVE

The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending.

METHODS

A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or "weight" the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20.

RESULTS

The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P<.001; and £389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, P=.006; £246, P<.001; and £362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20.

CONCLUSIONS

Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

Health policy experts' perspectives on implementing mental health specialist video consultations in routine primary care - a qualitative interview study

BACKGROUND

Many patients with mental disorders are treated by their general practitioner (GP). Innovative technology-based integrated care models (e.g., mental health specialist video consultations) have been proposed to facilitate access to specialist services in primary care settings. While perspectives of patients and providers have been examined, there is little insight into the perspectives of health policy experts on such models. The purpose of this study was to examine the perspectives of health policy experts on (1) current challenges for continuity of care, (2) anticipated benefits and barriers for implementation of mental health specialist video consultations along with (3) practical and regulative preconditions for sustained implementation in primary care.

METHODS

In a cross-sectional qualitative study, we conducted 15 semi-structured interviews with health policy experts representing various stakeholders in the German health care system: health insurances, governmental bodies, clinicians' professional associations, and patient representatives. Following a critical realism approach, we applied a qualitative inductive content analysis to derive key themes from the material.

RESULTS

Health policy experts saw long waiting times for patients and a lack of collaboration between in- and outpatient mental health services as well as mental health specialists and GPs as main barriers for current continuity of care. Health policy experts also felt that video consultations bear great potential to foster coordinated care between GPs and specialists and ensure timely referral for severely burdened patients. Increased workload for the general practice staff to facilitate video consultations and difficulties in establishing reliable therapeutic alliances between patients and specialists via remote treatment were considered as major barriers. Health policy experts varied significantly in their level of knowledge concerning legal frameworks and regulations pertaining to video consultations. However, the implementation of appropriate reimbursement schemes and sufficient data protection were regarded as the major regulative challenges.

CONCLUSIONS

Health policy experts mostly consider mental health specialist video consultations as a promising way to overcome current challenges for the management of patients with mental disorders at the interface between primary and specialist care. To ensure sustained implementation, a multi-stakeholder approach accounting for the perspective of health policy experts, patients, and providers should be followed.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00012487.

Therapists' Experience of Video Consultation in Specialized Mental Health Services During the COVID-19 Pandemic: Qualitative Interview Study

Background

As part of political and professional development with increased focus on including service users within mental health services, these services are being transformed. Specifically, they are shifting from institutional to noninstitutional care provision with increased integration of the use of electronic health and digitalization. In the period from March to May 2020, COVID-19 restrictions forced rapid changes in the organization and provision of mental health services through the increased use of digital solutions in therapy.

Objective

The aim of this study was to develop and advance comprehensive knowledge about how therapists experience the use of video consultation (VC). To reach this objective, we evaluated therapists’ experiences of using VC in specialized mental health services in the early phase of COVID-19 restrictions. The following questions were explored through interviews: Which opportunities and challenges appeared when using VC during the period of COVID-19 restrictions? In a short-term care pathway, for whom does VC work and for whom does it not work?

Methods

This study employed a qualitative approach based on an abductive strategy and hermeneutic-phenomenological methodology. Therapists and managers in mental health departments in a hospital were interviewed via Skype for Business from March to May 2020, using a thematic interview guide that aimed to encourage reflections on the use of VC during COVID-19 restrictions.

Results

Therapists included in this study experienced advantages in using VC under circumstances that did not permit face-to-face consultations. The continuity that VC offered the service users was seen as a valuable asset. Various negative aspects concerning the therapeutic environment such as lack of safety for the most vulnerable service users and topics deemed unsuitable for VC lowered the therapists’ overall impression of the service. The themes that arose in the data analysis have been categorized in the following main topics: (1) VC—“it’s better than nothing”; (2) VC affects therapists’ work situation—opportunities and challenges in working conditions; and (3) challenges of VC when performing professional assessment and therapy on the screen.

Conclusions

Experiences with VC in a mental health hospital during COVID-19 restrictions indicate that there are overall advantages to using VC when circumstances do not permit face-to-face consultations. Nevertheless, various negative aspects in the use of VC lowered the therapists’ overall impression of VC. Further qualitative research is needed, and future studies should focus on service users’ experiences, cocreation between different stakeholders, and how to scale up the use of VC while ensuring that the service provided is appropriate, safe, and available.

An online randomized controlled trial and survey of behavioural factors influencing patients' willingness to attend a video consultation

OBJECTIVES

To examine whether the phrasing of a hospital appointment invitation influences patient preference to attend in person or by video. The study also explores patient capabilities, opportunities, and motivations to attend video consultations.

DESIGN

A randomized controlled trial followed by a cross-sectional survey.

METHODS

Participants (1,481 total, 780 females) were residents of the United Kingdom who self-identified as being diagnosed with a chronic disease. Participants considered one of three hypothetical invitations. In one group, participants were invited to attend in person. Those in another group were invited to attend by video. These participants could either accept the invitation or request the other option. In the final 'active choice' group, participants were asked to choose to attend either in-person or by video appointment. Then, all participants responded to open- and closed-ended items about attending video consultations.

RESULTS

When the default option was in person, 25% of participants chose video consultation, compared with 41% in the active choice group (RR = 1.65, 95% CI: 1.37-1.99, p < .001) and 65% in the default video group (RR = 2.60, 95% CI: 2.20-2.96, p < .001). Closed-ended responses suggested that younger patients and those with previous experience were more likely to prefer video consultations. Most open-ended responses contained themes about opportunities, followed by motivations and then capabilities.

CONCLUSIONS

Patients are more likely to express a preference to attend by video when video is the default option. The real-world effectiveness of this intervention is more likely to be realized where hospitals also support patient capabilities, opportunities, and motivations.

Modeling the Implementation Context of a Telemedicine Service: Work Domain Analysis in a Surgical Setting

BACKGROUND

A telemedicine service enabling remote surgical consultation had shown promising results. When the service was to be scaled up, it was unclear how contextual variations among different clinical sites could affect the clinical outcomes and implementation of the service. It is generally recognized that contextual factors and work system complexities affect the implementation and outcomes of telemedicine. However, it is methodologically challenging to account for context in complex health care settings. We conducted a work domain analysis (WDA), an engineering method for modeling and analyzing complex work environments, to investigate and represent contextual influences when a telemedicine service was to be scaled up to multiple hospitals.

OBJECTIVE

We wanted to systematically characterize the implementation contexts at the clinics participating in the scale-up process. Conducting a WDA would allow us to identify, in a systematic manner, the functional constraints that shape clinical work at the implementation sites and set the sites apart. The findings could then be valuable for informed implementation and assessment of the telemedicine service.

METHODS

We conducted observations and semistructured interviews with a variety of stakeholders. Thematic analysis was guided by concepts derived from the WDA framework. We identified objects, functions, priorities, and values that shape clinical procedures. An iterative "discovery and modeling" approach allowed us to first focus on one clinic and then readjust the scope as our understanding of the work systems deepened.

RESULTS

We characterized three sets of constraints (ie, facets) in the domain: the treatment facet, administrative facet (providing resources for procedures), and development facet (training, quality improvement, and research). The constraints included medical equipment affecting treatment options; administrative processes affecting access to staff and facilities; values and priorities affecting assessments during endoscopic retrograde cholangiopancreatography; and resources for conducting the procedure.

CONCLUSIONS

The surgical work system is embedded in multiple sets of constraints that can be modeled as facets of the system. We found variations between the implementation sites that might interact negatively with the telemedicine service. However, there may be enough motivation and resources to overcome these initial disruptions given that values and priorities are shared across the sites. Contrasting the development facets at different sites highlighted the differences in resources for training and research. In some cases, this could indicate a risk that organizational demands for efficiency and effectiveness might be prioritized over the long-term outcomes provided by the telemedicine service, or a reduced willingness or ability to accept a service that is not yet fully developed or adapted. WDA proved effective in representing and analyzing these complex clinical contexts in the face of technological change. The models serve as examples of how to analyze and represent a complex sociotechnical context during telemedicine design, implementation, and assessment.

Multilevel structures and human agency in relation to email consultations: A strong structuration theory analysis of the Danish general practice setting

In recent years and throughout the developed world, policymakers have encouraged the implementation of digital patient-clinician interaction. Our focus is on the Danish general practice setting where email consultations were implemented as a mandatory service in 2009 and now constitute 21% of all consultations in general practice. Drawing upon strong structuration theory (SST), our analysis sets out to explore how email consultations are represented in structures on macro, meso and micro-levels and how the interplay between structures and agents plays out with respect to possible alignments, tensions and adjustments. We analyze data from policy documents on the macro and meso-levels, data from clinics' websites (meso-level) and data from interviews with GPs and patients (micro-level) (n = 53). Our findings show that the introduction of email consultation as a new health technology is a key site for development in email consultation practice, professional boundary setting and adjustments within the doctor-patient relationship. Our findings thus demonstrate that email consultation can be considered a dynamic component of a socio-technical network rather than a static medium for simple health transactions or information delivery. Based on these findings, we recommend that, for future implementation of patient-clinician digital communication it is important to investigate the multiple sources of influence on telecare practices and to see its intended users as agents who actively shape their own care motivated by opinions, relationships and values.

[Incorporation of telephone care into the provision of primary care and its effects on patient health and satisfaction: Proposal]

We present a review, analysis and proposal for the implantation, development and evaluation of telephone attention in primary care, focused as a new modality of offer that responds to standardized requirements of safety, efficacy, efficiency and balance not always easy to achieve, between the interests of users and professionals.

An Environmental Scan of Virtual "Walk-In" Clinics in Canada: Comparative Study

Background

Canada has been slow to implement virtual care relative to other countries. However, in recent years, the availability of on-demand, “walk-in” virtual clinics has increased, with the COVID-19 pandemic contributing to the increased demand and provision of virtual care nationwide. Although virtual care facilitates access to physicians while maintaining physical distancing, there are concerns regarding the continuity and quality of care as well as equitable access. There is a paucity of research documenting the availability of virtual care in Canada, thus hampering the efforts to evaluate the impacts of its relatively rapid emergence on the broader health care system and on individual health.

Objective

We conducted a national environmental scan to determine the availability and scope of virtual walk-in clinics, cataloging the services they offer and whether they are operating through public or private payment.

Methods

We developed a power term and implemented a structured Google search to identify relevant clinics. From each clinic meeting our inclusion criteria, we abstracted data on the payment model, region of operation, services offered, and continuity of care. We compared clinics operating under different payment models using Fisher exact tests.

Results

We identified 18 virtual walk-in clinics. Of the 18 clinics, 10 (56%) provided some services under provincial public insurance, although 44% (8/18) operated on a fully private payment model while an additional 39% (7/18) charged patients out of pocket for some services. The most common supplemental services offered included dermatology (15/18, 83%), mental health services (14/18, 78%), and sexual health (11/18, 61%). Continuity, information sharing, or communication with the consumers’ existing primary care providers were mentioned by 22% (4/18) of the clinics.

Conclusions

Virtual walk-in clinics have proliferated; however, concerns about equitable access, continuity of care, and diversion of physician workforce within these models highlight the importance of supporting virtual care options within the context of longitudinal primary care. More research is needed to support quality virtual care and understand its effects on patient and provider experiences and the overall health system utilization and costs.

Remote home visits: Exploring the concept and applications of remote home visits within health and social care settings

Introduction

This study consulted intended users and adopters of technology about a remote home visit application called Virtual Visit Approach. Participants were shown a video of a ‘mock’ remote home visit and asked to discuss the potential benefits, barriers and uses they could envisage.

Methods

Purposive sampling brought together stakeholders, patients and public representatives to capture thoughts, feelings and views in co-design workshops. Primary qualitative data were collected in real time. Post workshop, they were analysed and categorised into key themes and subthemes.

Findings

The opportunity to conduct remote home visits was regarded as a positive adjunct to usual practice. However, concerns about the quality of remote assessments were expressed by participants in the workshops.

Conclusion

The NHS response to COVID-19 sparked a national roll out of the use of video conferencing technology. The opportunity to access technology to conduct remote visits and consultations, has instigated a seismic change in the way healthcare is delivered now and for the future. However, there is much we do not yet know about the impact on the intended adopters and users of remote visits and consultations. This study demonstrated the importance of involving intended adopters and users in the co-design of technology to explore potential benefits, barriers and uses providing valuable insights to inform future design and development.

Using Virtual Patients to Explore the Clinical Reasoning Skills of Medical Students: Mixed Methods Study

BACKGROUND

Improving clinical reasoning skills-the thought processes used by clinicians to formulate appropriate questions and diagnoses-is essential for reducing missed diagnostic opportunities. The electronic Clinical Reasoning Educational Simulation Tool (eCREST) was developed to improve the clinical reasoning of future physicians. A feasibility trial demonstrated acceptability and potential impacts; however, the processes by which students gathered data were unknown.

OBJECTIVE

This study aims to identify the data gathering patterns of final year medical students while using eCREST and how eCREST influences the patterns.

METHODS

A mixed methods design was used. A trial of eCREST across 3 UK medical schools (N=148) measured the potential effects of eCREST on data gathering. A qualitative think-aloud and semistructured interview study with 16 medical students from one medical school identified 3 data gathering strategies: Thorough, Focused, and Succinct. Some had no strategy. Reanalysis of the trial data identified the prevalence of data gathering patterns and compared patterns between the intervention and control groups. Patterns were identified based on 2 variables that were measured in a patient case 1 month after the intervention: the proportion of Essential information students identified and the proportion of irrelevant information gathered (Relevant). Those who scored in the top 3 quartiles for Essential but in the lowest quartile for Relevant displayed a Thorough pattern. Those who scored in the top 3 quartiles for Relevant but in the lowest quartile for Essential displayed a Succinct pattern. Those who scored in the top 3 quartiles on both variables displayed a Focused pattern. Those whose scores were in the lowest quartile on both variables displayed a Nonspecific pattern.

RESULTS

The trial results indicated that students in the intervention group were more thorough than those in the control groups when gathering data. The qualitative data identified data gathering strategies and the mechanisms by which eCREST influenced data gathering. Students reported that eCREST promoted thoroughness by prompting them to continuously reflect and allowing them to practice managing uncertainty. However, some found eCREST to be less useful, and they randomly gathered information. Reanalysis of the trial data revealed that the intervention group was significantly more likely to display a Thorough data gathering pattern than controls (21/78, 27% vs 6/70, 9%) and less likely to display a Succinct pattern (13/78, 17% vs 20/70, 29%; χ²₃=9.9; P=.02). Other patterns were similar across groups.

CONCLUSIONS

Qualitative data suggested that students applied a range of data gathering strategies while using eCREST and that eCREST encouraged thoroughness by continuously prompting the students to reflect and manage their uncertainty. Trial data suggested that eCREST led students to demonstrate more Thorough data gathering patterns. Virtual patients that encourage thoroughness could help future physicians avoid missed diagnostic opportunities and enhance the delivery of clinical reasoning teaching.

Use of alternative consultation forms in Danish general practice in the initial phase of the COVID-19 pandemic - a qualitative study

Background

Attempts to manage the COVID-19 pandemic have led to radical reorganisations of health care systems worldwide. General practitioners (GPs) provide the vast majority of patient care, and knowledge of their experiences with providing care for regular health issues during a pandemic is scarce. Hence, in a Danish context we explored how GPs experienced reorganising their work in an attempt to uphold sufficient patient care while contributing to minimizing the spread of COVID-19. Further, in relation to this, we examined what guided GPs’ choices between telephone, video and face-to-face consultations.

Methods

This study consisted of qualitative interviews with 13 GPs. They were interviewed twice, approximately three months apart in the initial phase of the pandemic, and they took daily notes for 20 days. All interviews were audio recorded, transcribed, and inductively analysed.

Results

The GPs re-organised their clinical work profoundly. Most consultations were converted to video or telephone, postponed or cancelled. The use of video first rose, but soon declined, once again replaced by an increased use of face-to-face consultations. When choosing between consultation forms, the GPs took into account the need to minimise the risk of COVID-19, the central guidelines, and their own preference for face-to-face consultations. There were variations over time and between the GPs regarding which health issues were dealt with by using video and/or the telephone. For some health issues, the GPs generally deemed it acceptable to use video or telephone, postpone or cancel appointments for a short term, and in a crisis situation. They experienced relational and technical limitations with video consultation, while diagnostic uncertainty was not regarded as a prominent issue

Conclusion

This study demonstrates how the GPs experienced telephone and video consultations as being useful in a pandemic situation when face-to-face consultations had to be severely restricted. The GPs did, however, identify several limitations similar to those known in non-pandemic times. The weighing of pros and cons and their willingness to use these alternatives shifted and generally diminished when face-to-face consultations were once again deemed viable. In case of future pandemics, such alternatives seem valuable, at least for a short term.

Parental expectations before and after 12-month experience with video consultations combined with regular outpatient care for children with type 1 diabetes: a qualitative study

AIM

To explore parents' expectations of the perceived barriers to and benefits of 1 year of monthly video consultations combined with regular outpatient care of children with type 1 diabetes.

METHODS

The Virtual Diabetes Outpatient Clinic for Children and Youth (VIDIKI) study was a controlled, multicentre, perennial study with 240 participants from northern Germany. Fifty-four qualitative interviews with parents were analysed using qualitative content analysis. Before the intervention, 30 interviews were conducted to assess parents' expectations, and after 1 year, 24 interviews evaluated the experienced benefits and barriers to video consultations.

RESULTS

Four main topics were identified from parents' responses to the video consultation. The main advantages of the video consultation compared with standard care were a higher frequency of contact for optimized insulin dosing and saving time; difficulties with internet connections were identified as the main barrier. A feeling of increased confidence with respect to insulin dosing was directly associated with telemedicine. Digital prescriptions and meeting the same diabetologist in both outpatient and telemedical care were mentioned as important improvements. The majority of interviewees preferred intervals of 4-6 weeks between video consultations.

CONCLUSION

The higher frequency of contact with the diabetes team was considered a great relief by parents of children with type 1 diabetes. Apart from the time savings and flexibility in appointments, the most important advantages were the higher frequency of contact leading to short-term therapy adjustments and an increase in the ability to adjust therapy independently. (German Clinical Trials Registry No: DRKS00012645).

Telemedicine consultations with physicians in Swedish primary care: a mixed methods study of users' experiences and care patterns

OBJECTIVE

The study aimed to explore users' experiences and care patterns concerning telemedicine consultations with physicians in Swedish primary care from 2017 to 2019.Design and participants: A mixed methods study involving 26 qualitative interviews with users of telemedicine consultations from a national sample, complemented by a quantitative registry study of data from 10,400 users in a Swedish region.

RESULTS

Users mainly described telemedicine consultations as a positive experience and perceived that the service met their current health care needs. Users also valued high accessibility, timesaving, and the contribution to ecological sustainability. Users felt competent about choosing when to use telemedicine consultations, most commonly for less severe health care concerns. This was confirmed by the quantitative results; only a few users had other care contacts within physical primary care before, or after, the telemedicine consultation, attended acute care or phoned 1177 Health Care Guidance.

CONCLUSIONS

This study provides a rare account of users' experiences of telemedicine consultations. Users expressed satisfaction with this up-to-date use of health care resources for them as individuals, the health care system, and the environment. Telemedicine consultations were perceived as efficient and safe according to users. In addition, the study shows a low degree of further physical contacts in primary care or in acute care related to the telemedicine consultations.Key pointsUsers have positive experiences of telemedicine consultations with physicians and experienced that the service had meet their actual needs for health care.Users were mainly satisfied with the service and highlighted the value of high accessibility.Users experienced that telemedicine consultants provided an alternative care service for mostly minor health problems, perceiving them to save time and resources for themselves, the health care system, and the environment.Most telemedicine consultations did not result in additional contacts with 1177 Health Care Guidance, physical visits to primary care, or acute health care.Telemedicine consultations with physicians were mainly used by persons aged 0-30 years and need to be further developed to suit other age groups.

The use of telehealth in psychological counselling of adult vulnerable patients with rheumatic diseases and diabetes: An explorative study inspired by participatory design (Preprint)

Background

Objective

Methods

Results

Conclusions

Remote Musculoskeletal Consultations: A Survey of General Practitioner Registrars' Level of Confidence, Acceptability, and Management

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has accelerated the shift towards remote consultations in the medical field, including musculoskeletal (MSK) appointments. General practitioner (GP) registrars are now routinely conducting many MSK consultations remotely; however, very little is known of their level of confidence and satisfaction regarding this new and evolving scenario, or how this may impact patient management of patients. In this study, we aimed to understand GP registrars' level of confidence and satisfaction with respect to remote MSK consultations, and the perceived impact on patient management. Study design This study involved a cross-sectional online survey of GP registrars in the West Midlands, which was conducted in January 2021. Methods The survey asked for ranked responses to questions comparing face-to-face consulting methods with remote consulting, focusing on confidence, satisfaction, onward investigations, and referral activity. Statistical analysis was performed using the R software version 4.0.3. Results The overall survey response was 21.2% (n=312/1,471). Of the respondents, 85.9% of GP registrars had not received any training to prepare them for remote MSK consultations. GP registrars generally felt that they were more confident when treating patients face-to-face compared to remote consultations (p<0.001). This was true for general MSK complaints as well as specific assessments of the hand, shoulder, spine, hip, knee, and ankle; 36.2% of GP registrars were not satisfied and 51.0% thought that their patients were not satisfied with the current quality of remote MSK consultations. Of note, 77.6% of GP registrars said that they were more likely to request additional investigations, and 75.6% stated that they were more likely to refer patients to a specialist after a remote MSK consultation. Conclusion This study highlights the need for further training to better equip primary care doctors for remote MSK consultations. With tailored training, GP registrars could offer more streamlined remote patient care for MSK complaints.

"A decade's worth of work in a matter of days": The journey to telehealth for the whole population in Australia

Introduction

Internationally the COVID-19 pandemic has triggered a dramatic and unprecedented shift in telehealth uptake as a means of protecting healthcare consumers and providers through remote consultation modes. Early in the pandemic, Australia implemented a comprehensive and responsive set of policy measures to support telehealth. Initially targeted at protecting vulnerable individuals, including health professionals, this rapidly expanded to a “whole population” approach as the pandemic evolved. This policy response supported health system capacity and community confidence by protecting patients and healthcare providers; creating opportunities for controlled triage, remote assessment and treatment of mild COVID-19 cases; redeploying quarantined or isolated health care workers (HCWs); and maintaining routine and non-COVID healthcare.

Purpose

This paper provides a review of the literature regarding telephone and video consulting, outlines the pre-COVID background to telehealth implementation in Australia, and describes the national telehealth policy measures instituted in response to COVID-19. Aligned with the existing payment system for out of hospital care, and funded by the national health insurance scheme, a suite of approximately 300 temporary telehealth Medicare-subsidised services were introduced. Response to these initiatives was swift and strong, with 30.01 million services, at a cost of AUD $1.54 billion, claimed in the first six months.

Findings

This initiative has been a major policy success, ensuring the safety of healthcare consumers and healthcare workers during a time of great uncertainty, and addressing known financial risks and barriers for health service providers. The risks posed by COVID-19 have radically altered the value proposition of telehealth for patients and clinicians, overcoming many previously encountered barriers to implementation, including willingness of clinicians to adopt telehealth, consumer awareness and demand, and the necessity of learning new ways of conducting safe consultations. However, ensuring the quality of telehealth services is a key ongoing concern.

Conclusions

Despite a preference by policymakers for video consultation, the majority of telehealth consults in Australia were conducted by telephone. The pronounced dominance of telephone item numbers in early utilisation data suggests there are still barriers to video-consultations, and a number of challenges remain before the well-described benefits of telehealth can be fully realised from this policy and investment. Ongoing exposure to a range of clinical, legislative, insurance, educational, regulatory, and interoperability concerns and solutions, driven by necessity, may drive changes in expectations about what is desirable and feasible – among both patients and clinicians.

Cross-sectoral communication by bringing together patient with cancer, general practitioner and oncologist in a video-based consultation: a qualitative study of oncologists' and nurse specialists' perspectives

Shared care models in the field of cancer aim to improve care coordination, role clarification and patient satisfaction. Cross-sectoral communication is pivotal. Involvement of patients may add to intended mechanisms.A randomised controlled trial 'The Partnership Study' tested the effect of bringing together patient, general practitioner (GP) and oncologist for a consultation conducted by video.

PURPOSE

As part of the process evaluation, this study aimed to explore experiences, attitudes and perspectives of the oncological department on sharing patient consultations with GPs using video.

METHODS

Four semistructured interviews with five oncologists and four nurse specialists were conducted in February 2020. We focused on the informants' experiences and reflections on the potential of future implementation of the concept 'inviting the GP for a shared consultation by video'. The analyses were based on an inductive, open-minded, hermeneutic phenomenological approach.

RESULTS

A total of six overall themes were identified: structuring consultation and communication, perceptions of GP involvement in cancer care, stressors, making a difference, alternative ways of cross-sector communication and needs for redesigning the model. The concept made sense and was deemed useful, but solving the many technical and organisational problems is pivotal. Case-specific tasks and relational issues were targeted by pragmatically rethinking protocol expectations and the usual way of communication and structuring patient encounters. Case selection was discussed as one way of maturing the concept.

CONCLUSION

This Danish study adds new insight into understanding different aspects of the process, causal mechanisms as well as the potential of future implementation of video-based tripartite encounters. Beyond solving the technical problems, case selection and organisational issues are important. Acknowledging the disruption of the usual workflow, the introduction of new phases of the usual encounter and the variety of patient-GP relationships to be embraced may help to better understand and comply with barriers and facilitators of communication and sharing.

TRIAL REGISTRATION NUMBER

NCT02716168.

Mental health specialist video consultations versus treatment as usual in patients with depression or anxiety disorders in primary care: study protocol for an individually randomised superiority trial (the PROVIDE-C trial)

BACKGROUND

Most people with mental disorders, including those with severe and chronic disorders, are treated solely by their general practitioner (GP). Nevertheless, specialised mental health care may be required for specific patients. Notably, the accessibility of mental health specialist care is mainly complicated by (a) long waiting times for an appointment with specialists, (b) long travel distances to specialists, particularly in rural and remote areas, and (c) patients' reservations about mental health specialist care (including fear of being stigmatised by seeking such care). To mitigate those barriers, technology-based integrated care models have been proposed. The purpose of this study is to examine the effectiveness and cost-effectiveness of a mental health specialist video consultations model versus treatment as usual in patients with depression or anxiety disorders in primary care.

METHODS

In an individually randomised, prospective, two-arm superiority trial with parallel group design, N = 320 patients with anxiety and/or depressive disorder will be recruited in general practices in Germany. The intervention includes a newly developed treatment model based on video consultations with focus on diagnostics, treatment planning, and short-term intervention by mental health specialists. We will systematically compare the effectiveness, cost-effectiveness, and adverse effects of this new model with usual care by the GP: the primary outcome is the absolute change in the mean depressive and anxiety symptom severity measured on the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) from baseline to 6 months after baseline assessment. Follow-up in both groups will be conducted by blinded outcome assessors at 6 months and 12 months after baseline. The main analysis will be based on the intention-to-treat principle. We will optimise the likelihood of treatment effectiveness by strict inclusion criteria for patients, enhanced intervention integrity, and conducting a process evaluation.

DISCUSSION

To the best of our knowledge, this is the first confirmatory study on a video-based, integrated care model for the treatment of anxiety and depressive disorders in GP patients in Germany.

TRIAL REGISTRATION

ClinicalTrials.gov, United States National Institutes of Health NCT04316572 . Prospectively registered on 20 March 2020.

Tele-Mental Health Utilization Among People with Mental Illness to Access Care During the COVID-19 Pandemic

Shortly after the COVID-19 pandemic arrived at the United States, mental health services moved towards using tele-mental health to provide care. A survey about resilience and tele-mental health was developed and conducted with ForLikeMinds' members and followers. Correlational analysis was used to examine relationships between quantitative variables. A phenomenological approach was used to analyze open questions responses. Sixteen percent of participants were coping well with the pandemic; 50% were coping okay; and 34% said that they were coping poorly. Three main themes emerged from the qualitative analysis: accessibility to care; self-care strategies; and community support and relationship. The responses from participants seems to reflect the combination of two main factors-the challenges they were facing in accessing care through tele-mental health plus the mental health consequences from COVID-19. This survey reflects the importance of building innovative strategies to create a working alliance with people who need care through tele-mental health.

Virtual Consultations: Young People and Their Parents' Experience

Purpose

Evaluate the experience of virtual consultations for young people and their families and assess whether young people are being offered a confidential space as part of these virtual encounters.

Patients and Methods

An anonymous online survey was sent to young people age 10-18 y.o. who had experienced at least one virtual consultation with an adolescent medicine tertiary service in the United Kingdom between March 13th and June 13th 2020 mostly associated with, but not exclusively, management of chronic fatigue syndrome or medically unexplained symptoms. Responses from the survey were analysed by two authors who independently coded the common themes reported by the participants.

Results

Fifty young people and their families participated in the survey. Eighty-eight percent reported feeling prepared for virtual appointments, 90% found them helpful, 88% felt that they were private and 86% reported they would find further virtual appointments helpful. Positive impacts reported were no need to travel (38%) and the continuity of care (36%). Many of our participants reported no negative impact (39%) and felt that nothing needed to be improved (56%). The most frequent improvement reported was the provision of a quality video call (34%). Only 36% of young people had the opportunity to speak in confidence to the health care provider without their parents' presence.

Conclusion

Virtual appointments are perceived as safe and helpful by the young people and their families. Professionals should offer a confidential remote space for young people to speak without their parents.

Delivering remote consultations: Talking the talk

INTRODUCTION

There is an increasing affinity for remote health consultations (including telephone and virtual platforms), enabling new models of accessing services to evolve. Whilst many key skills are transferable from traditional to remote consultations, there is even greater emphasis on verbal communication skills during these interactions.

PURPOSE

This masterclass considers the communication skills required for delivering remote health care consultations, in particular focussing on: 12 interactional features in an opening sequence of a remote call; active listening; how to offer advice using the Ask-Offer-Ask framework; and subtleties in phrasing and prosody when closing a call that may indicate a level of satisfaction (or otherwise).

IMPLICATIONS

In planning for digitally-enabled services to become mainstream, the differences in communication between remote and face-to-face consultations must be recognised and embraced.

Remote Clinics During Coronavirus Disease 2019: Lessons for a Sustainable Future

Background

The coronavirus disease 2019 (COVID-19) pandemic has led to a focus on non-face-to-face (NF2F) orthopedic clinics. In this study, our aim was to establish whether NF2F clinics are sustainable according to the “triple bottom line” framework by taking into account the impact on patients, the planet, and the financial cost.

Methodology

This retrospective cohort study was carried out at a large district general hospital with 261 patients identified as having undergone face-to-face (F2F) or NF2F orthopedic consultations (April 2020). These patients were contacted by telephone to establish their experience, mode of transport, and preference for future consultations. Data were also collected relating to environmental and financial costs to the patient and the trust.

Results

The final analysis included 180 (69%) patients: 42% had an F2F consultation and 58% NF2F consultation. There was no significant difference between each group in terms of convenience, ease of communication, subjective patient safety, or overall satisfaction rating (p > 0.05). Overall, 80% of NF2F patients would be happy with virtual consultations in the future. The mean journey distance was 18.6 miles leading to a reduction in total carbon emissions of 563.9 kgCO₂e (66%), equating to 2,106 miles in a medium-sized car. The hospital visit carbon cost (heating, lighting, and waste generation) was reduced by 3,967 kgCO₂e (58%). The financial cost (petrol and parking) was also reduced by an average of £8.96 per person.

Conclusions

NF2F consultations are aligned to the National Health Service’s “Long Term Plan”: (i) delivering high patient satisfaction with equivalent outcomes as F2F consultations; (ii) reducing carbon emissions from transportation and hospital running; and (iii) becoming cheaper.

Video as an alternative to in-person consultations in outpatient renal transplant recipient follow-up: a qualitative study

Background

Renal transplant recipients have to see a nephrologist for regular follow-up for the rest of their lives. To reduce the burden for the patients, video consultation can be an alternative to traditional in-person hospital consultations. The aim of the current study was, from the perspectives of patients and health care providers, to investigate the perceived benefits and challenges of using video consultations in outpatient renal transplant recipient follow-up.

Methods

Patients (i.e., renal transplant recipients; n = 18) alternated between regular in-person follow-up consultations and video consultations. Patients and health care providers were then invited to participate in semi-structured interviews. The interviews were analyzed using thematic analysis.

Results

Patients interviewed (n = 15) were median 53 years old (range 37–64) and 53% female. The video consultation solution used in the study turned out to have major technical deficiencies. Despite the technical challenges, however, the majority of the patients reported appreciating being able to alternate between video and in-person hospital consultations. Main benefits reported included not needing to travel to the hospital and thereby saving time, less focus on being chronically ill and potential economic benefits for patients and society. The health care providers (n = 3) also valued the benefits provided by the use of video consultations, but described the reoccurring technical challenges as disruptive. The fact that patients were in a stable phase of their health condition and already had an established, trusting relationship with their nephrologist, acted as facilitators for success. Possible challenges and harms described included concerns related to security, confidentiality and interruptions, as well as the potential need for physical examinations.

Conclusions

Benefits from using video consultations as an alternative to in-person consultations may outweigh potential technological challenges for patients as well as health care providers. A long-lasting mutually trusting relationship between patient and provider may be an important prerequisite for the experienced benefits of using video consultation. Findings also indicate that starting such care delivery changes in a small-scale, with a few selected patients in a stable phase of their condition, may be an important factor for success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02284-3.

Testing and implementing video consulting for outpatient appointments: using quality improvement system thinking and codesign principles

Increasing demand for outpatient appointments (OPA) is a global challenge for healthcare providers. Non-attendance rates are high, not least because of the challenges of attending hospital OPAs due to transport difficulties, cost, poor health, caring and work responsibilities. Digital solutions may help ameliorate these challenges. This project aimed to implement codesigned outpatient video consultations across National Health Service (NHS) Highland using system-wide quality improvement approaches to implementation, involving patients, carers, clinical and non-clinical staff, national and local strategic leads. System mapping; an intensive codesign process involving extensive stakeholder engagement and real-time testing; Plan, Do, Study, Act cycles; and collection of clinician and patient feedback were used to optimise the service. Standardised processes were developed and implemented, which made video consulting easy to use for patients, embedded video into routine health service systems for clinicians and non-clinical staff, and automated much of the administrative burden. All clinicians and staff are using the system and both groups identified benefits in terms of travel time and costs saved. Transferable lessons for other services are identified, providing a practical blueprint for others to adapt and use in their own contexts to help implement and sustain video consultation services now and in the future.

Physicians' experiences of video consultation with patients at a public virtual primary care clinic: a qualitative interview study

OBJECTIVE

To describe physicians' experiences of video consultation with new patients visiting a publicly owned virtual primary care clinic.

DESIGN

In this qualitative study, data were collected from semi-structured individual interviews and analysed by systematic text condensation.

SETTING

A publicly owned virtual primary care clinic in Region Västra Götaland, Sweden.

SUBJECTS

Ten primary care physicians working at the clinic.

RESULTS

Connecting with a patient over video could be either straightforward or deficient, depending on communication and the patient's condition. Clinical experience, communication skills, and involving patients throughout the consultation and examination were crucial for assessments over video where patients were guided to perform self-examination. The flexibility of work and the regulated assignment online were positive for the physicians' work situation and wellbeing. Providing video consultation within the same organisation as the patient's regular health centre was considered to facilitate patient care and safety. Video consultation was considered suitable for some diagnoses and for some patients not able to reach a primary healthcare centre, though doubts were expressed about the healthcare and social benefits of this virtual care service.

CONCLUSION

For the physicians, video consultation induced changes in the basis for assessment of primary care patients. The limitations on informational exchange demanded an extended form of patient involvement founded upon consultation skills, clinical experience and new skills for virtual examination. Combining virtual care with traditional general practice has the potential to reduce the workload for the individual physician and ensure medical competence in virtual primary care. Video consultation experienced suitable in some situations, but easy access to it expressed problematic in terms of medical prioritisation in healthcare.KEY POINTSVideo consultation is suitable for primary care visits for some patients, but physicians' experiences of this are rarely studied. •Clinical experience and consultation skills are important for video assessment of primary care patients which involves physician-guided patient self-examination.•Video consultation facilitates care in some situations and could benefit from the provider being connected to patient's regular health centre.•Virtual care offers a flexible way of working but challenges healthcare prioritisation from the primary care physician's perspective.

Factors that influence patient preferences for virtual consultations in an orthopaedic rehabilitation setting: a qualitative study

OBJECTIVES

To identify, characterise and explain factors that influence patient preferences, from the perspective of patients and clinicians, for virtual consultations in an orthopaedic rehabilitation setting.

DESIGN

Qualitative study using semi-structured interviews and abductive analysis.

SETTING

A physiotherapy and occupational therapy department situated within a tertiary orthopaedic centre in the UK.

PARTICIPANTS

Patients who were receiving orthopaedic rehabilitation for a musculoskeletal problem. Occupational therapists, physiotherapists or therapy technicians involved in the delivery of orthopaedic rehabilitation for patients with a musculoskeletal problem.

RESULTS

Twenty-two patients and 22 healthcare professionals were interviewed. The average interview length was 48 minutes. Four major factors were found to influence preference: the situation of care (the ways that patients understand and explain their clinical status, their treatment requirements and the care pathway), the expectations of care (influenced by a patients desire for contact, psychological status, previous care and perceived requirements), the demands on the patient (due to each patients respective social situation and the consequences of choice) and the capacity to allocate resources to care (these include financial, infrastructural, social and healthcare resources).

CONCLUSION

This study has identified key factors that appear to influence patient preference for virtual consultations in orthopaedic rehabilitation. A conceptual model of these factors, derived from empirical data, has been developed highlighting how they combine and compete. A series of questions, based on these factors, have been developed to support identification of preferences in a clinical setting.

Teleconsultations at a Pediatrics Outpatient Service in COVID-19 Pandemic: First Results

Objective: Describe our experiences using teleconsultation approach to care for pediatric subspecialty follow-up patients during pandemic period. Methods: Synchronous teleconsultation solution was developed and implemented as a multiplatform/multimodality service, capable or running on desktop browsers and smartphones, and capable to handle chat, audio, and video. Term of consent was applied. Absolute number and percentage of patients assisted, as well as the form of consultation and the mean of attendance per patient were presented. Results: A telemedicine service was started using tools provided by The Santa Catarina State Integrated Telemedicine and Telehealth System offering real-time chat, through an online-based teleconsultation service. We assisted 75 patients in 109 consultations in 3 months, of which 69.7% were performed by chat. Mean of consultations per patient was 1.45. Conclusion: To our knowledge this is the first service in offering this modality of medicine for Brazilian public health care system. Patients and health care personnel reported satisfaction.

Suitability of Video Consultations During the COVID-19 Pandemic Lockdown: Cross-sectional Survey Among Norwegian General Practitioners

Background

The COVID-19 pandemic imposed an acute, sharp rise in the use of video consultations (VCs) by general practitioners (GPs) in Norway.

Objective

This study aims to document GPs’ experiences with the large-scale uptake of VCs in the natural experiment context of the pandemic.

Methods

A nationwide, cross-sectional online survey was conducted among Norwegian GPs during the pandemic lockdown (April 14-May 3, 2020). Each respondent was asked to evaluate up to 10 VCs. Basic demographic characteristics of the GPs and their practices were collected. The associations between GPs’ perceived suitability of the VCs, the nature of the patients’ main problems, prior knowledge of the patients (relational continuity), and follow-up of previously presented problems (episodic continuity) were explored using descriptive statistics, diagrams, and chi-square tests.

Results

In total, 1237 GPs (26% of the target group) responded to the survey. Among these, 1000 GPs offered VCs, and 855 GPs evaluated a total of 3484 VCs. Most GPs who offered VCs (1000/1237; 81%) had no experience with VCs before the pandemic. Overall, 51% (1766/3476) of the evaluated VCs were considered to have similar or even better suitability to assess the main reason for contact, compared to face-to-face consultations. In the presence of relational continuity, VCs were considered equal to or better than face-to-face consultations in 57% (1011/1785) of cases, as opposed to 32% (87/274) when the patient was unknown. The suitability rate for follow-up consultations (episodic continuity) was 61% (1165/1919), compared to 35% (544/1556) for new patient problems. Suitability varied considerably across clinical contact reasons. VCs were found most suitable for anxiety and life stress, depression, and administrative purposes, as well as for longstanding or complex problems that normally require multiple follow-up consultations. The GPs estimate that they will conduct about 20% of their consultations by video in a future, nonpandemic setting.

Conclusions

Our study of VCs performed in general practice during the pandemic lockdown indicates a clear future role for VCs in nonpandemic settings. The strong and consistent association between continuity of care and GPs’ perceptions of the suitability of VCs is a new and important finding with considerable relevance for future primary health care planning.

Use of Teleconsultations in a Regional Stereotactic Radiosurgery Service: Pilot Study

Background

The National Health Service Long Term Plan details plans to make digital interactions available to all patients in 5 years. Teleconsultations can improve access to specialist services; however, there is a lack of evidence for the use of teleconsultations in an oncology setting in the United Kingdom.

Objective

We aim to describe a service evaluation of teleconsultations for patients attending a regional brain metastases clinic. These patients have unique travel restrictions that prevent them from driving.

Methods

From April to October 2018, all patients attending the brain metastases clinic were offered the choice of teleconsultation in place of a face-to-face appointment. Feedback was assessed using a satisfaction questionnaire, and data of all clinic attendances were collected.

Results

A total of 69 individual patients had 119 appointments over the duration of the pilot, of which 36 (30.2%) were new patient appointments and 73 (61.3%) were follow-ups. Of the 69 patients, 24 (35%) took part in teleconsultations (41/119, 34.5%). User satisfaction was high, and no patients who took part in a teleconsultation reverted to face-to-face appointments. These patients avoided 2521 miles (61.6 miles per appointment) of hospital-associated travel and travel costs of £441.48 (US $599.83) to £10.78 (US $14.65) per appointment.

Conclusions

Teleconsultations appear to be acceptable in this cohort of patients with brain metastases attending a regional stereotactic radiosurgery service with the potential for significant savings in travel and expenses.

Cancer patient experience of telephone clinics implemented in light of COVID-19

Introduction

Due to the pandemic of COVID-19 a number of National Health Service (NHS) Trusts in the UK adopted telephone consultations for patients who were shielding. As the pandemic continues to affect these services an evaluation was conducted to determine whether telephone consultations implemented during the pandemic should be maintained long term. The objective was to evaluate this new service and to understand patient experience.

Methods

This study was conducted via a telephone survey. Staff working in the Macmillan centres across the Trust called patients to survey them about their experience of telephone consultations. Data were collected 23/06/20 – 17/07/20. A mix of eight open and closed questions were asked. Data were collected on an Excel spreadsheet and patient identifiable information was anonymised.

Results

55 patients accepted to participate in this study. Out of 55, 39 patients rated the phone consultation they had as either 4 or 5 out of 5. When asked if they would like to continue with phone clinics 33 said they would. The majority of consultations were conducted by doctors (43/55). Patients commented they had received great support from their healthcare professionals and they felt that phone consultations were safer in the current climate. Three of the patients felt the calls were rushed and others found it difficult to discuss pain management, sides effects and post-surgery issues.

Conclusions

This evaluation provides a brief snapshot of the experience cancer patients are having with phone clinics. A re-evaluation will take place once video consultations are implemented.

Pain management programmes via video conferencing: a rapid review

OBJECTIVES

During the current COVID-19 pandemic, healthcare has been transformed by the rapid switch from in person care to use of remote consulting, including video conferencing technology. Whilst much has been published on one-to-one video consultations, little literature exists on use of this technology to facilitate group interventions. Group pain management programmes are a core treatment provided by many pain services. This rapid review aimed to identify the extent of use of video conferencing technology for delivery of group pain management programmes and provide an overview of its use.

METHODS

A rapid review of the literature published up to April 2020 (PubMed, PsycINFO and PEDro) was performed. The search string consisted of three domains: pain/CP (MeSH term) AND Peer group[MeSH] AND Videoconferencing[MeSH]/Telemedicine[MeSH]/Remote Consultation[MeSH]. The studies were of poor methodological quality and study design, and interventions and chronic pain conditions were varied.

RESULTS

Literature searching yielded three eligible papers for this review. All studies had low methodological quality and risk of bias. Heterogeneity and variability in outcome reporting did not allow any pooling of data. The results demonstrated that videoconferencing for delivery of group programmes is possible, yet there is little extant literature on how to develop, deliver and measure outcomes of such programmes.

CONCLUSIONS

This review demonstrates that there is little evidence to support or guide the use of synchronous videoconferencing to deliver pain management programmes. We present issues to consider, informed by this review and our experience, when implementing video conferencing. Study quality of existing work is variable, and extensive future research is necessary.

Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework

BACKGROUND

COVID-19 has thrust video consulting into the limelight, as health care practitioners worldwide shift to delivering care remotely. Evidence suggests that video consulting is acceptable, safe, and effective in selected conditions and settings. However, research to date has mostly focused on initial adoption, with limited consideration of how video consulting can be mainstreamed and sustained.

OBJECTIVE

This study sought to do the following: (1) review and synthesize reported opportunities, challenges, and lessons learned in the scale-up, spread, and sustainability of video consultations, and (2) identify transferable insights that can inform policy and practice.

METHODS

We identified papers through systematic searches in PubMed, CINAHL, and Web of Science. Included articles reported on synchronous, video-based consultations that had spread to more than one setting beyond an initial pilot or feasibility stage, and were published since 2010. We used the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework to synthesize findings relating to 7 domains: an understanding of the health condition(s) for which video consultations were being used, the material properties of the technological platform and relevant peripherals, the value proposition for patients and developers, the role of the adopter system, organizational factors, wider macro-level considerations, and emergence over time.

RESULTS

We identified 13 papers describing 10 different video consultation services in 6 regions, covering the following: (1) video-to-home services, connecting providers directly to the patient; (2) hub-and-spoke models, connecting a provider at a central hub to a patient at a rural center; and (3) large-scale top-down evaluations scaled up or spread across a national health administration. Services covered rehabilitation, geriatrics, cancer surgery, diabetes, and mental health, as well as general specialist care and primary care. Potential enablers of spread and scale-up included embedded leadership and the presence of a telehealth champion, appropriate reimbursement mechanisms, user-friendly technology, pre-existing staff relationships, and adaptation (of technology and services) over time. Challenges tended to be related to service development, such as the absence of a long-term strategic plan, resistance to change, cost and reimbursement issues, and the technical experience of staff. There was limited articulation of the challenges to scale-up and spread of video consultations. This was combined with a lack of theorization, with papers tending to view spread and scale-up as the sum of multiple technical implementations, rather than theorizing the distinct processes required to achieve widespread adoption.

CONCLUSIONS

There remains a significant lack of evidence that can support the spread and scale-up of video consulting. Given the recent pace of change due to COVID-19, a more definitive evidence base is urgently needed to support global efforts and match enthusiasm for extending use.

Survey of CAMHS clinicians about their experience of remote consultation: brief report

The Covid-19 crisis necessitated rapid adoption of remote consultations across National Health Service (NHS) child and adolescent mental health services (CAMHS). This study aimed to understand practitioners' experiences of rapid implementation of remote consultations across CAMHS in one NHS trust in the east of England. Data were collected through a brief questionnaire documenting clinicians' experiences following remote delivery of services. The questionnaire began before 'lockdown' and focused on assessment consultations (n = 102) as part of a planned move to virtual assessment. As the roll-out of remote consultations was extended at lockdown, we extended the questionnaire to include all remote clinical contacts (n = 202). Despite high levels of initial concern, clinicians' reports were positive overall; importantly, however, their experiences varied by team. When restrictions on face-to-face working are lifted, a blended approach of remote and face-to-face service delivery is recommended to optimise access and capacity while retaining effective and safe care.

Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach

Background

Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes.

Methods

An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored.

Discussion

It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Structure and work process for implementing medical teleconsultation in the Brazilian National Health System, a cross-sectional study using 2017-2018 data

OBJECTIVE

To compare the structure and the work process in Primary Care for implementing medical teleconsultation in municipalities in different regions and with different population sizes (<25,000; 25,000-100,000; >100,000 inhabitants).

METHODS

Cross-sectional study, with descriptive and bivariate analysis, using data from 2017-2018 to assess the availability of computers with internet access, webcam, microphone, speaker, as well as to assess the work processes (use of Telehealth, service supply and demand control center, and communication flow).

RESULTS

30,346 primary health centers and 38,865 teams were evaluated. Presence of teleconsultation equipment in the health centers ranged from 1.2% in large northern municipalities to 26.7% in small southern municipalities. Established work process ranged from 10.7% in small northern municipalities to 39.5% in large southern municipalities. Compared to the South, medium-sized municipalities in the North (OR=0.14 - 95%CI 0.11;0.17) and Northeast (OR=0.21 - 95%CI 0.18;0.25) regions were less likely to have the necessary equipment.

CONCLUSION

Significant regional inequalities call for investments in Digital Health.

Tools to Support Self-Care Monitoring at Home: Perspectives of Patients with Heart Failure

Self-care monitoring at home can be a challenge for patients with heart failure (HF). Tools that leverage information and communication technology (ICT), comprise medical devices, or have written material may support their efforts at home. The aim of this study was to describe HF patients’ experiences and their prioritization of tools that support, or could support, self-care monitoring at home. A descriptive qualitative design employing semi-structured interviews was used with HF patients living at home and attending an HF outpatient clinic in Norway. We used a deductive analysis approach, using the concept of self-care monitoring with ICT tools, paper-based tools, medical devices, and tools to consult with healthcare professionals (HCPs) as the categorization matrix. Nineteen HF patients with a mean age of 64 years participated. ICT tools are used by individual participants to identify changes in their HF symptoms, but are not available by healthcare services. Paper-based tools, medical devices, and face-to-face consultation with healthcare professionals are traditional tools that are available and used by individual participants. HF patients use traditional and ICT tools to support recognizing, identifying, and responding to HF symptoms at home, suggesting that they could be used if they are available and supplemented by in-person consultation with HCPs.

Investigating Patients' Intention to Continue Using Teleconsultation to Anticipate Postcrisis Momentum: Survey Study

Background

The COVID-19 crisis has drastically changed care delivery with teleconsultation platforms experiencing substantial spikes in demand, helping patients and care providers avoid infections and maintain health care services. Beyond the current pandemic, teleconsultation is considered a significant opportunity to address persistent health system challenges, including accessibility, continuity, and cost of care, while ensuring quality.

Objective

This study aims at identifying the determinants of patients’ intention to continue using a teleconsultation platform. It extends prior research on information technology use continuance intention and teleconsultation services.

Methods

Data was collected in November 2018 and May 2019 with Canadian patients who had access to a teleconsultation platform. Measures included patients’ intention to continue their use; teleconsultation usefulness; teleconsultation quality; patients’ trust toward the digital platform, its provider. and health care professionals; and confirmation of patients’ expectations toward teleconsultation. We used structural equation modeling employing the partial least squares component-based technique to test our research model and hypotheses.

Results

We analyzed a sample of 178 participants who had used teleconsultation services. Our findings revealed that confirmation of expectations had the greatest influence on continuance intention (total effects=0.722; P<.001), followed by usefulness (total effects=0.587; P<.001) and quality (total effects=0.511; P<.001). Usefulness (β=.60; P<.001) and quality (β=.34; P=.01) had direct effects on the dependent variable. The confirmation of expectations had direct effects both on usefulness (β=.56; P<.001) and quality (β=.75; P<.001) in addition to having an indirect effect on usefulness (indirect effects=0.282; P<.001). Last, quality directly influenced usefulness (β=.34; P=.002) and trust (β=.88; P<.001). Trust does not play a role in the context under study.

Conclusions

Teleconsultation is central to care going forward, and it represents a significant lever for an improved, digital delivery of health care in the future. We believe that our findings will help drive long-term teleconsultation adoption and use, including in the aftermath of the current COVID-19 crisis, so that general care improvement and greater preparedness for exceptional situations can be achieved.

Digital consultations in Swedish primary health care: a qualitative study of physicians' job control, demand and support

Background

Digital consultation with primary care physicians via mobile telephone apps has been spreading rapidly in Sweden since 2014. Digital consultation allows remote working because physicians can work from home, outside their traditional primary care environment. Despite the spread of digital consultation in primary care, there is a lack of knowledge concerning how the new service affects physicians’ psychosocial work environment. Previous research has focused primarily on the patients’ point of view and the cost-effectiveness of digital consultation. Hence, there is a paucity of studies from the perspective of physicians, focusing on their psychosocial work environment. The aim of this study was to investigate primary care physicians’ perceived work demands, control over working processes, and social support when providing digital consultation to primary care patients.

Methods

The study has a qualitative design, using semi-structured interviews conducted in Sweden in 2019. We used a purposeful sampling strategy to achieve a heterogeneous sample of physicians who represented a broad spectrum of experiences and perceptions. The interviews were conducted by video meeting, telephone, or a personal meeting, depending on what suited the participant best. The interview questions were informed by the Job Demand-Control-Support (JDCS) model, which was also used as the framework to analyze the data by categorizing the physicians’ perceptions and experiences into the three categories of the model (Demand, Control, Support), in the deductive analysis of the data.

Results

Analysis of the data yielded 9 subcategories, which were mapped onto the 3 categories of the JDCS model. Overall, the participants saw numerous benefits with digital consultations, not only with regard to their own job situation but also for patients and the health care system in general even though they identified some shortcomings and risks with digital care.

Conclusions

This study has demonstrated that physicians perceive working with digital consultation as flexible with a high grade of autonomy and reasonable to low demands. According to the participants, digital consultation is not something you can work with full time if medical skills and abilities are to be maintained and developed.

Maternity services in the UK during the coronavirus disease 2019 pandemic: a national survey of modifications to standard care

OBJECTIVE

To explore the modifications to maternity services across the UK, in response to the coronavirus disease 2019 (COVID-19) pandemic, in the context of the pandemic guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM) and NHS England.

DESIGN

National survey.

SETTING

UK maternity services during the COVID-19 pandemic.

POPULATION OR SAMPLE

Healthcare professionals working within maternity services.

METHODS

A national electronic survey was developed to investigate local modifications to general and specialist maternity care during the COVID-19 pandemic, in the context of the contemporaneous national pandemic guidance. After a pilot phase, the survey was distributed through professional networks by the RCOG and co-authors. The survey results were presented descriptively in tabular and graphic formats, with proportions compared using chi-square tests.

MAIN OUTCOME MEASURES

Service modifications made during the pandemic.

RESULTS

A total of 81 respondent sites, 42% of the 194 obstetric units in the UK, were included. They reported substantial and heterogeneous maternity service modifications. Seventy percent of units reported a reduction in antenatal appointments and 56% reported a reduction in postnatal appointments; 89% reported using remote consultation methods. A change to screening pathways for gestational diabetes mellitus was reported by 70%, and 59% had temporarily removed the offer of births at home or in a midwife-led unit. A reduction in emergency antenatal presentations was experienced by 86% of units.

CONCLUSIONS

This national survey documents the extensive impact of the COVID-19 pandemic on maternity services in the UK. More research is needed to understand the impact on maternity outcomes and experience.

TWEETABLE ABSTRACT

A national survey showed that UK maternity services were modified extensively and heterogeneously in response to COVID-19.

Agile Application of Video Telemedicine During the COVID-19 Pandemic

Background The coronavirus disease 2019 (COVID-19) pandemic led to a need to introduce video telemedicine for outpatients as an emergency measure without widespread stakeholder consultation. The patient and clinician experience of video outpatient consultation during the peak of the pandemic was studied for acceptability and to gather recommendations to improve the service during continuing infection control measures. Methods Outpatient video telemedicine was introduced over a 14-day period including the provision of equipment, systems integration and stakeholder communication. Patient and clinician experience were measured between 15 April 2020 and 5 May 2020. Results A total of 43 patients and 79 clinicians provided feedback. Of the patients, 86% were above the age of 30 years, with the largest patient group aged 51-70 years. Patient experience was positive. All (100%) patients found joining the video consultation easy; 93% of them recommended to use it for future consultations. Clinician satisfaction was >90% with sound and video quality. Patients were less satisfied than clinicians in that they had communicated everything they wanted to (86% versus 95%). All (100%) patients thought that the video telemedicine solution met their needs, but 25% of clinicians believed that the patient experience of a video consultation was worse than a face-to-face clinic appointment. The three significant factors identified for introducing video consultations were successful IT, improved patient experience and digital healthcare records. Conclusions In the COVID-19 crisis, video telemedicine played a central role in outpatient consultations with excellent levels of success. With some differences in satisfaction level, clinicians significantly underestimate the level of patient satisfaction with outpatient video consultation.

Investigating the Acceptance of Video Consultation by Patients in Rural Primary Care: Empirical Comparison of Preusers and Actual Users

BACKGROUND

The ongoing digitalization in health care is enabling patients to receive treatment via telemedical technologies, such as video consultation (VC), which are increasingly being used by general practitioners. Rural areas in particular exhibit a rapidly aging population, with an increase in associated health issues, whereas the level of attraction for working in those regions is decreasing for young physicians. Integrating telemedical approaches in treating patients can help lessen the professional workload and counteract the trend toward the spatial undersupply in many countries. As a result, an increasing number of patients are being confronted with digital treatment and new forms of care delivery. These novel ways of care engender interactions with patients and their private lives in unprecedented ways, calling for studies that incorporate patient needs, expectations, and behavior into the design and application of telemedical technology within the field of primary care.

OBJECTIVE

This study aims to unveil and compare the acceptance-promoting factors of patients without (preusers) and with experiences (actual users) in using VC in a primary care setting and to provide implications for the design, theory, and use of VC.

METHODS

In total, 20 semistructured interviews were conducted with patients in 2 rural primary care practices to identify and analyze patient needs, perceptions, and experiences that facilitate the acceptance of VC technology and adoption behavior. Both preusers and actual users of VC were engaged, allowing for an empirical comparison. For data analysis, a procedure was followed based on open, axial, and selective coding.

RESULTS

The study delivers factors and respective subdimensions that foster the perceptions of patients toward VC in rural primary care. Factors cover attitudes and expectations toward the use of VC, the patient-physician relationship and its impact on technology assessment and use, patients' rights and obligations that emerge with the introduction of VC in primary care, and the influence of social norms on the use of VC and vice versa. With regard to these factors, the results indicate differences between preusers and actual users of VC, which imply ways of designing and implementing VC concerning the respective user group. Actual users attach higher importance to the perceived benefits of VC and their responsibility to use it appropriately, which might be rooted in the technological intervention they experienced. On the contrary, preusers valued the opinions and expectations of their peers.

CONCLUSIONS

The way the limitations and potential of VC are perceived varies across patients. When practicing VC in primary care, different aspects should be considered when dealing with preusers, such as maintaining a physical interaction with the physician or incorporating social cues. Once the digital intervention takes place, patients tend to value benefits such as flexibility and effectiveness over potential concerns.

Determining if Telehealth Can Reduce Health System Costs: Scoping Review

Background

Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.

Objective

This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.

Methods

A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.

Results

The cost analyses reviewed provided evidence that telehealth reduced costs when health system–funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.

Conclusions

Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.