Crisis as opportunity, disruption and exposure: Exploring emergent responses to crisis through digital technology

Innovating agri-food business models after the Covid-19 pandemic: The impact of digital technologies on the value creation and value capture mechanisms

This paper investigates the phenomenon of business models innovation (BMI) empowered by digital technologies and activated as a response to Covid-19 crisis. In fact, during the crisis numerous digital redesigns of businesses occurred to pursue both continuity and competitive advantage. Among these, the food retail sector has undergone under the pressure of the crisis intense digital changes, which, however, have not yet been investigated under the theoretical lens of BMI. To fill this gap, the paper analyzes the digital actions taken during the pandemic crisis by two large food retailers, namely Walmart and Carrefour. Covering a wide temporal interval of the pandemic evolution and reviewing multiple geographical markets, the authors interpreted the grocer's digital responses to the crisis in terms of innovation in value creation and capture mechanisms. As a result, three phases of digital BMI have been reconstructed, each characterized by specific mechanisms of value creation and capture experienced by the two grocers during the pandemic. Leveraging these findings, the paper proposes a model capable of defining how digital BMI takes place in response to crises. Results broaden theoretical knowledge and practical suggestions on digital BMI in terms of enabling factors, actionable value mechanisms, and future business opportunities.

IT and the Quality and Efficiency of Mental Health Care in a Time of COVID-19: Case Study of Mental Health Providers in England

BACKGROUND

In England, COVID-19 has significantly affected mental health care and tested the resilience of health care providers. In many areas, the increased use of IT has enabled traditional modes of service delivery to be supported or even replaced by remote forms of provision.

OBJECTIVE

This study aimed to assess the use and impact of IT, in remote service provision, on the quality and efficiency of mental health care during the pandemic. We drew on sociotechnical systems theory as a conceptual framework to help structure the gathering, analysis, and interpretation of data.

METHODS

We conducted a national scoping survey that involved documentary analysis and semistructured interviews with 6 national stakeholders and case studies of 4 purposefully selected mental health providers in England involving interviews with 53 staff members.

RESULTS

Following the outbreak of COVID-19, mental health providers rapidly adjusted their traditional forms of service delivery, switching to digital and telephone consultations for most services. The informants provided nuanced perspectives on the impact on the quality and efficiency of remote service delivery during the pandemic. Notably, it has allowed providers to attend to as many patients as possible in the face of COVID-19 restrictions, to the convenience of both patients and staff. Among its negative effects are concerns about the unsuitability of remote consultation for some people with mental health conditions and the potential to widen the digital divide and exacerbate existing inequalities. Sociotechnical systems theory was found to be a suitable framework for understanding the range of systemic and sociotechnical factors that influence the use of technology in mental health care delivery in times of crisis and normalcy.

CONCLUSIONS

Although the use of IT has boosted mental health care delivery during the pandemic, it has had mixed effects on quality and efficiency. In general, patients have benefited from the convenience of remote consultation when face-to-face contact was impossible. In contrast, patient choice was often compromised, and patient experience and outcomes might have been affected for some people with mental health conditions for which remote consultation is less suitable. However, the full impact of IT on the quality and efficiency of mental health care provision along with the systemic and sociotechnical determinants requires more sustained and longitudinal research.

Remote care in UK general practice: baseline data on 11 case studies

Background

Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.

Methods

Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.

Results

Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.

Conclusions

General practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Remote care in UK general practice: baseline data on 11 case studies

BACKGROUND

Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.

METHODS

Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.

RESULTS

Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.

CONCLUSIONS

General practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Theorising the shift to video consulting in the UK during the COVID-19 pandemic: Analysis of a mixed methods study using practice theory

We studied video consulting in the National Health Service during 2020-2021 through video interviews, an online survey and online discussions with people who had provided and participated in such consultations. Video consulting had previously been used for selected groups in limited settings in the UK. The pandemic created a seismic shift in the context for remote consulting, in which video transformed from a niche technology typically introduced by individual clinicians committed to innovation and quality improvement to offering what many felt was the only safe way to deliver certain types of healthcare. A new practice emerged: a co-constitution of technology and healthcare made possible by new configurations of equipment, connectivity and physical spaces. Despite heterogeneous service settings and previous experiences of video consulting, we found certain kinds of common changes had made video consulting possible. We used practice theory to analyse these changes, interpreting the commonalities found in our data as changes in purpose, material arrangements and a relaxing of rules about security, confidentiality and location of consultations. The practice of video consulting was equivocal. Accounts of, and preferences for, video consulting varied as did the extent to which it was sustained after initial take-up. People made sense of video consulting in different ways, ranging from interpreting video as offering a new modality of healthcare for the future to a sub-optimal, temporary alternative to in-person care. Despite these variations, video consulting became a recognisable social phenomenon, albeit neither universally adopted nor consistently sustained. The nature of this social change offers new perspectives on processes of implementation and spread and scale-up. Our findings have important implications for the future of video consulting. We emphasise the necessity for viable material arrangements and a continued shared interpretation of the meaning of video consulting for the practice to continue.

IT-business alignment, big data analytics capability, and strategic decision-making: Moderating roles of event criticality and disruption of COVID-19

Prior research has confirmed the importance of IT-business alignment (ITBA) and big data analytics capability (BDAC) in supporting firms' strategic decision-making under normal circumstances. However, the global outbreak of COVID-19 has significantly changed firms' strategic decision-making landscapes and raised questions regarding the effects of ITBA and BDAC on strategic decision-making as conditioned by COVID-19 characteristics. In this study, we contextualize two important event impact factors (i.e., event criticality and event disruption) in the context of COVID-19 and examine their contingent roles in the effects of ITBA and BDAC on strategic decision-making. Our analyses, based on two-round, multi-respondents matched survey data collected from 175 Chinese firms to elucidate the differential moderating roles of event criticality and disruption of COVID-19 in the impact of ITBA and BDAC on strategic decision speed and quality. The results indicate the event criticality of COVID-19 strengthens the effects of ITBA on decision speed and quality but weakens the influence of BDAC on decision quality. Meanwhile, the event disruption of COVID-19 weakens the influence of ITBA on decision speed and quality but strengthens the effect of BDAC on decision speed and quality. These findings have important theoretical and practical implications, which we discuss in the conclusion.

A Postphenomenological Perspective On the Changing Nature of Work

In this essay, I take a postphenomenological perspective on tracing work transformation during the pandemic, arguing that this perspective helps develop novel sensitivities to the nature of work. Postphenomenology brings into high relief the view on work as reliant on sensory performances and embodied relations, complementing already rich accounts of work being reliant on discursive interactions, social order, and spatiality. The focus of postphenomenology on 'non-neutrality' and the multistability of technology provides a useful lens for revealing a multiplicity of changes, encompassing both augmentations and reductions of work experiences and evaluating their consequences for the actors involved. Finally, its attention to the transparency of technology amidst the embodied experiences gives a handle on the role of materiality in the performance of work and may be taken up as informing design efforts. A case study vignette of physiotherapy work during lockdown is offered as an illustration of applying some of the postphenomenological ideas.

The role of information infrastructures in scaling up video consultations during Covid-19: a mixed-methods case study into opportunity, disruption and exposure (Preprint)

Background

Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a “burning platform” for scaling up such services. As health care organizations look to expand and maintain the use of video in the “new normal,” it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward.

Objective

This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19.

Methods

A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants (eg, clinicians, managers, administrators, and IT support), ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al’s 3 perspectives on crisis and digital change: as opportunity (for accelerated innovation and removal of barriers to experimentation), disruption (to organizational practices, generating new dependencies and risks), and exposure (of vulnerabilities in both people and infrastructure).

Results

Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an “organizing vision” for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use.

Conclusions

For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed.

Protocol: Remote care as the 'new normal'? Multi-site case study in UK general practice

Background

Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices' varied experiences over time as they seek to establish remote forms of accessing and delivering care.

Methods

This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups).

Results anticipated

We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint).

Conclusion

By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

Innovating under pressure: Adopting digital technologies in social care organizations during the COVID-19 crisis

To provide ongoing support for vulnerable groups during the COVID-19 pandemic, social care organizations had to shift abruptly to e-health solutions. Qualitative data from three cases illustrate that, more than a year into the pandemic, those adoptions of digital technologies developed differently; the current study aims to shed light on the processes that lead to such differences. Notably, the first organization resisted the large-scale use of digital technologies; the second faced intra-organizational disagreement about the role of digital technology for care provision; and the third organization struggled but managed a broader, more successful adoption of digital technology. The multiple case study findings contribute to extant literature, by (1) detailing the digital innovation process, focusing on the crucial adoption process for digital technology; (2) demonstrating that champions and a shared vision can both enable and constrain the adoption of digital technologies in crisis situations; (3) emphasizing the importance of individual members’ professional identities for determining adoption of digital technologies; and (4) reflecting on the conscious use of transformation practices, even in the ad hoc setting of adopting digital technology during a crisis.

Telepsychiatry: learning from the pandemic

This article draws on research and clinical experience to discuss how and when to use video consultations in mental health settings. The appropriateness and impact of virtual consultations are influenced by the patient's clinical needs and social context, as well as by service-level socio-technical and logistical factors.

To Engage or Not to Engage with AI for Critical Judgments: How Professionals Deal with Opacity When Using AI for Medical Diagnosis

Artificial intelligence (AI) technologies promise to transform how professionals conduct knowledge work by augmenting their capabilities for making professional judgments. We know little, however, about how human-AI augmentation takes place in practice. Yet, gaining this understanding is particularly important when professionals use AI tools to form judgments on critical decisions. We conducted an in-depth field study in a major U.S. hospital where AI tools were used in three departments by diagnostic radiologists making breast cancer, lung cancer, and bone age determinations. The study illustrates the hindering effects of opacity that professionals experienced when using AI tools and explores how these professionals grappled with it in practice. In all three departments, this opacity resulted in professionals experiencing increased uncertainty because AI tool results often diverged from their initial judgment without providing underlying reasoning. Only in one department (of the three) did professionals consistently incorporate AI results into their final judgments, achieving what we call engaged augmentation. These professionals invested in AI interrogation practices—practices enacted by human experts to relate their own knowledge claims to AI knowledge claims. Professionals in the other two departments did not enact such practices and did not incorporate AI inputs into their final decisions, which we call unengaged “augmentation.” Our study unpacks the challenges involved in augmenting professional judgment with powerful, yet opaque, technologies and contributes to literature on AI adoption in knowledge work.

Let's Connect to Keep the Distance: How SMEs Leverage Information and Communication Technologies to Address the COVID-19 Crisis

COVID-19 caused significant challenges for small and medium-sized enterprises (SMEs) in the event industry. To address these challenges, many SMEs leveraged information and communication technologies (ICTs), with some even emerging strengthened from the crisis. Drawing on the technology-organization-environment framework and technology-affordances-and-constraints theory, we investigate the adoption of ICTs as a crisis response strategy in 10 SMEs in the German business event (e.g., corporate events, conferences) industry. Our findings reveal that ICT adoption not only depends on rational decisions based on organizational, environmental, and technological characteristics, but also on these dimensions' interrelationship and the specific ICTs' affordances and constraints. Introducing readily available ICTs (e.g., video-conferencing) has significant potential in addressing physical distancing in the short and medium term, while more sophisticated ICTs (e.g., virtual reality) are more likely to gain importance in the long term. Thus, we expand our understanding of organizational technology adoption and ICT-enabled crisis response strategies in SMEs.

Crisis as driver of digital transformation? Scottish local governments’ response to COVID-19

The response to the COVID-19 pandemic has, from the outset, been characterized by a strong focus on real-time data intelligence and the use of data-driven technologies. Against this backdrop, this article investigates the impacts of the pandemic on Scottish local government’s data practices and, in turn, whether the crisis acted as a driver for digital transformation. Mobilizing the literatures on digital government transformation, and on the impacts of crises on public administrations, the article provides insights into the dynamics of digital transformation during a heightened period of acute demands on the public sector. The research evidences an intensification of public sector data use and sharing in Scottish local authorities, with focus on health-related data and the integration of existing datasets to gather local intelligence. The research reveals significant changes related to the technical and social systems of local government organizations. These include the repurposing and adoption of information systems, the acceleration of inter and intraorganizational data sharing processes, as well as changes in ways of working and in attitudes toward data sharing and collaborations. Drawing on these findings, the article highlights the importance of identifying and articulating specific data needs in relation to concrete policy questions in order to render digital transformation relevant and effective. The article also points to the need of addressing the persistent systemic challenges underlying public sector data engagement through, on one hand, sustained investment in data capabilities and infrastructures and, on the other, support for cross-organizational collaborative spaces and networks.

Achieving Spread, Scale Up and Sustainability of Video Consulting Services During the COVID-19 Pandemic? Findings From a Comparative Case Study of Policy Implementation in England, Wales, Scotland and Northern Ireland

Requirements for physical distancing as a result of COVID-19 and the need to reduce the risk of infection prompted policy supporting rapid roll out of video consulting across the four nations of the UK-England, Northern Ireland, Scotland and Wales. Drawing on three studies of the accelerated implementation and uptake of video consulting across the four nations, we present a comparative and interpretive policy analysis of the spread and scale-up of video consulting during the pandemic. Data include interviews with 59 national level stakeholders, 55 health and social care staff and 30 patients, 20 national documents, responses to a UK-wide survey of NHS staff and analysis of routine activity data. Sampling ensured variations in geography, clinical context and adoption progress across the combined dataset. Comparative analysis was guided by theory on policy implementation and crisis management. The pandemic provided a "burning platform" prompting UK-wide policy supporting the use of video consulting in health care as a critical means of managing the risk of infection and a standard mode of provision. This policy push facilitated interest in video consulting across the UK. There was, however, marked variation in how this was put into practice across the four nations. Pre-existing infrastructure, policies and incentives for video consulting in Scotland, combined with a collaborative system-level approach, a program dedicated to developing video-based services and resourcing and supporting staff to deliver them enabled widespread buy-in and rapid spread. In England, Wales and Northern Ireland, pre-existing support for digital health (e.g., hardware, incentives) and virtual care, combined with reduced regulation and "light touch" procurement managed to override some (but by no means all) cultural barriers and professional resistance to implementing digital change. In Northern Ireland and Wales, limited infrastructure muted spread. In all three countries, significant effort at system level to develop, review and run video consulting programs enabled a substantial number of providers to change their practice, albeit variably across settings. Across all four nations ongoing uncertainty, potential restructuring and tightening of regulations, along with difficulties inherent in addressing inequalities in digital access, raise questions about the longer-term sustainability of changes to-date.

Let's Connect to Keep the Distance: How SMEs Leverage Information and Communication Technologies to Address the COVID-19 Crisis

COVID-19 caused significant challenges for small and medium-sized enterprises (SMEs) in the event industry. To address these challenges, many SMEs leveraged information and communication technologies (ICTs), with some even emerging strengthened from the crisis. Drawing on the technology-organization-environment framework and technology-affordances-and-constraints theory, we investigate the adoption of ICTs as a crisis response strategy in 10 SMEs in the German business event (e.g., corporate events, conferences) industry. Our findings reveal that ICT adoption not only depends on rational decisions based on organizational, environmental, and technological characteristics, but also on these dimensions' interrelationship and the specific ICTs' affordances and constraints. Introducing readily available ICTs (e.g., video-conferencing) has significant potential in addressing physical distancing in the short and medium term, while more sophisticated ICTs (e.g., virtual reality) are more likely to gain importance in the long term. Thus, we expand our understanding of organizational technology adoption and ICT-enabled crisis response strategies in SMEs.

Expanding Video Consultation Services at Pace and Scale in Scotland During the COVID-19 Pandemic: National Mixed Methods Case Study

Background

Scotland—a country of 5.5 million people—has a rugged geography with many outlying islands, creating access challenges for many citizens. The government has long sought to mitigate these through a range of measures including an ambitious technology-enabled care program. A strategy to develop a nationwide video consultation service began in 2017. Our mixed methods evaluation was commissioned in mid-2019 and extended to cover the pandemic response in 2020.

Objective

To draw lessons from a national evaluation of the introduction, spread, and scale-up of Scotland’s video consultation services both before and during the pandemic.

Methods

Data sources comprised 223 interviews (with patients, staff, technology providers, and policymakers), 60 hours of ethnographic observation (including in-person visits to remote settings), patient and staff satisfaction surveys (n=20,349), professional and public engagement questionnaires (n=5400), uptake statistics, and local and national documents. Fieldwork during the pandemic was of necessity conducted remotely. Data were analyzed thematically and theorized using the Planning and Evaluating Remote Consultation Services (PERCS) framework which considers multiple influences interacting dynamically and unfolding over time.

Results

By the time the pandemic hit, there had been considerable investment in material and technological infrastructure, staff training, and professional and public engagement. Scotland was thus uniquely well placed to expand its video consultation services at pace and scale. Within 4 months (March-June 2020), the number of video consultations increased from about 330 to 17,000 per week nationally. While not everything went smoothly, video was used for a much wider range of clinical problems, vastly extending the prepandemic focus on outpatient monitoring of chronic stable conditions. The technology was generally considered dependable and easy to use. In most cases (14,677/18,817, 78%), patients reported no technical problems during their postconsultation survey. Health care organizations’ general innovativeness and digital maturity had a strong bearing on their ability to introduce, routinize, and expand video consultation services.

Conclusions

The national-level groundwork before the pandemic allowed many services to rapidly extend the use of video consultations during the pandemic, supported by a strong strategic vision, a well-resourced quality improvement model, dependable technology, and multiple opportunities for staff to try out the video option. Scotland provides an important national case study from which other countries may learn.

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.