Digitized patient-provider interaction: How does it matter? A qualitative meta-synthesis

Family Caregiver Comfort with Telehealth Technologies: Differences by Race and Ethnicity in a Cross-Sectional Survey

Background: Telehealth has seen widespread use since the onset of the COVID-19 pandemic, and 82% patients required assistance in accessing their telehealth appointments. This assistance commonly comes from a family caregiver who may or may not be comfortable using the technologies associated with telehealth. The objective of our study was to analyze a demographically representative survey of U.S. family caregivers to understand the level of comfort using telehealth technologies among family caregivers. Methods: A secondary analysis of survey data collected during the COVID-19 pandemic in 2020. Level of caregiver comfort using computers, smartphones, and tablets was determined through three Likert-style questions. Proportional odds logistic regression was used to understand the associations between demographic variables and level of caregiver comfort using each technology, when adjusting for covariates. Results: A total of 340 caregivers were included in the analysis. Compared with non-Hispanic white caregivers, Asian caregivers had higher odds (odds ratio [OR] 3.14; 95% confidence interval [CI] 1.36, 8.02; p = 0.01) of expressing comfort using computers; black caregivers (OR 0.46; 95% CI 0.21, 0.98; p = 0.04) and Hispanic caregivers (OR 0.36; 95% CI 0.17, 0.79; p = 0.01) expressed lower odds of comfort using smartphones; and Asian caregivers had higher odds (OR 4.64; 95% CI 2.05, 11.69; p = 0.001) of expressing comfort using tablets. Conclusion and Implications: There are identified disparities in the level of technological comfort using computers, smartphones, and tablets by different racial and ethnic groups. Health systems should consider early stakeholder involvement in the design of telehealth technologies, culturally responsive training materials on telehealth technology use to reduce disparities in comfort using telehealth technologies.

Inaccessible Possibilities: experiences of using ICT to engage with services among young persons with disabilities

PURPOSE

The use of Information and communications technologies (ICT) in the public sector is widespread and on the increase. There is a need to develop knowledge regarding the end users experiences of using ICT to engage with services. This study aims to provide knowledge regarding young persons with disabilities or chronic disease experience using ICT to engage with health- and social care services.

MATERIALS AND METHODS

Nine young persons between 16 and 25, living with chronic disease or physical disability, participated in this study. The data was collected using semi-structured interviews. The interviews were recorded, transcribed verbatim and analysed using Constructivist Grounded Theory.

RESULTS

Three categories were identified that reflected the young persons' experiences with using ICT to engage with health and social care services. (1) Navigating in an information overflow, (2) Experiencing disparate dialogues, (3) Utilising the potential of ICT. The young persons experienced that ICT used for engaging with health and social care services did not necessarily fit their need, yet, they saw how ICT had potential to increase engagement with services, especially with an increased focus on dialogue. The findings can be subsumed by the core category Inaccessible Possibilities, illustrating both the potentials and the challenges ICT presented.

CONCLUSION

The study shows that although young persons are perceived as digitally native, they experienced challenges using ICT to engage with health- and social services. The poor fit of ICT combined with navigation- and accessibility issues, hinder engagement. However, ICT inhabit a potential to increase engagement, especially communication.IMPLICATIONS FOR REHABILITATIONYoung persons' experiences show that ICT can be useful for enhancing engagement with health and social care servicesICT provided by health and social services does not necessarily meet young persons need for dialogueAn increased focus on accessibility and design is necessary to ensure people with disabilities access to ICT used by health- and social care services.

Challenges and opportunities of telehealth digital equity to manage HIV and comorbidities for older persons living with HIV in New York State

BACKGROUND

Older persons living with HIV (PLWH) need routine healthcare to manage HIV and other comorbidities. This mixed methods study investigated digital equity, constituted as access, use and quality, of HIV and specialty telehealth services for PLWH > 50 years during the initial wave of the COVID-19 pandemic when services transitioned to remote care.

METHODS

A survey of closed and open-ended questions was administered to 80 English (N = 63) and Spanish (N = 17) speaking PLWH receiving HIV care at an Academic Medical Center (N = 50) or a Federally Qualified Health Center (N = 30) in New York State. Quantitative analyses examined characteristics predicting telehealth use and visit quality. Qualitative analyses utilized thematic coding to reveal common experiences. Results were integrated to deepen the interpretation.

RESULTS

Telehealth access and use were shaped by multiple related and unstable factors including devices and connectivity, technology literacy, and comfort including privacy concerns. Participants demonstrated their substantial effort to achieve the visit. The majority of patients with a telehealth visit perceived it as worse than an in-person visit by describing it as less interpersonal, and resulting in poorer outcomes, particularly participants with less formal education. Technology was not only a barrier to access, but also influenced perceptions of quality.

CONCLUSIONS

In the COVID-19 pandemic initial wave, barriers to using telehealth were unequally distributed to those with more significant access and use challenges. Beyond these barriers, examining the components of equity indicate further challenges replicating in-person care using telehealth formats for older PLWH. Work remains to establish telehealth as both equitable and desirable for this population.

Beyond the Point of No Return: A Discourse Analysis of Healthcare Professionals' Perceptions of Digitally Supported Person-Centred, Integrated, and Proactive Care

Most countries are facing a common challenge: a rise in the number of chronically ill patients and limited medical resources. The combination of digital support and the principles of person-centred, integrated, and proactive care (Digi-PIP care) services constitutes the most ambitious initiative for patients with long-term needs. While there is research on digital support, person-centred, integrated, and proactive care, the combination of these components has been less explored. The data set consisted of 29 qualitative interviews with healthcare professionals involved in four Nordic Digi-PIP care initiatives. Building on prevailing discourses on the modernisation of healthcare, we used discourse analysis to determine how the professionals discussed their perceptions and experiences of the care transformation initiatives. We identified four discourses illustrating that, despite challenges with adoption, the vision of Digi-PIP care was strongly embedded among participants across professions and contexts. In contrast to the discourses on their separate components, the emergent discourses on Digi-PIP care were surprisingly consistent. The new care model was found to be beneficial for patients, healthcare professionals, and society. Digitalisation may vitalise and even catalyse person-centred, integrated, and proactive practices. To the employees involved, Digi-PIP has moved beyond the point of no return; it is the future of modern healthcare.

Conceptualizing the digitalization of healthcare work: A metaphor-based Critical Interpretive Synthesis

The digitalization of healthcare work has gained center stage in academic debates spanning disciplines as diverse as medicine, sociology and STS. The different analytical interests and methodological traditions of these three strains of scholarship have, however, resulted in quite diverging approaches to this issue. Points of interest have ranged from the (disattended) promise of increased efficiency of healthcare work, to dynamics of task delegation, (re-)professionalization and (re-)distribution of invisible work, to the disruption of informal organization. Instead of studying these dynamics in practice, in this paper we foreground the potentiality for theory-making inherent in the systematic cross-contamination of different theoretical and disciplinary perspectives. We perform a Critical Interpretive Synthesis (CIS) centering the ways the digitalization of healthcare work has been investigated in recent STS, sociological and medical literature. To open up assumptions and insights intrinsic to each body of literature for scholars and practitioners in other fields, we propose here a metaphor-based variation on CIS approaches. We probe, in turn, what slime molds can teach us about STS's focus on interconnections and materiality, how we can better understand sociological analyses of invisible work exploring them through theatrical performances, and which lessons river engineering offers concerning medical scholarship's discussion of efficiency and proper healthcare work. Thinking through these metaphors, we conceptualize the digitalization of healthcare work as a phenomenon spanning, at once, the directionality of technological innovation trajectories and the open-endedness of situated changes in work practices. Based on our analysis, we propose focusing on technological scripts, and various forms of invisible work and informal organization as entry points into the study of the tension between directionality and open-endedness in the context of the digitalization of healthcare work.

General Practitioners' Perceptions of the Use of Wearable Electronic Health Monitoring Devices: Qualitative Analysis of Risks and Benefits

Background

The rapid diffusion of wearable electronic health monitoring devices (wearable devices or wearables) among lay populations shows that self-tracking and self-monitoring are pervasively expanding, while influencing health-related practices. General practitioners are confronted with this phenomenon, since they often are the expert-voice that patients will seek.

Objective

This article aims to explore general practitioners’ perceptions of the role of wearable devices in family medicine and of their benefits, risks, and challenges associated with their use. It also explores their perceptions of the future development of these devices.

Methods

Data were collected during a medical conference among 19 Swiss general practitioners through mind maps. Maps were first sketched at the conference and their content was later compared with notes and reports written during the conference, which allowed for further integration of information. This tool represents an innovative methodology in qualitative research that allows for time-efficient data collection and data analysis.

Results

Data analysis highlighted that wearable devices were described as user-friendly, adaptable devices that could enable performance monitoring and support medical research. Benefits included support for patients’ empowerment and education, behavior change facilitation, better awareness of personal medical history and body functioning, efficient information transmission, and connection with the patient’s medical network; however, general practitioners were concerned by a lack of scientific validation, lack of clarity over data protection, and the risk of stakeholder-associated financial interests. Other perceived risks included the promotion of an overly medicalized health culture and the risk of supporting patients’ self-diagnosis and self-medication. General practitioners also feared increased pressure on their workload and a compromised doctor–patient relationship. Finally, they raised important questions that can guide wearables’ future design and development, highlighting a need for general practitioners and medical professionals to be involved in the process.

Conclusions

Wearables play an increasingly central role in daily health-related practices, and general practitioners expressed a desire to become more involved in the development of such technologies. Described as useful information providers, wearables were generally positively perceived and did not seem to pose a threat to the doctor–patient relationship. However, general practitioners expressed their concern that wearables may fuel a self-monitoring logic, to the detriment of patients’ autonomy and overall well-being. While wearables can contribute to health promotion, it is crucial to clarify the logic underpinning the design of such devices. Through the analysis of group discussions, this study contributes to the existing literature by presenting general practitioners’ perceptions of wearable devices. This paper provides insight on general practitioners’ perception to be considered in the context of product development and marketing.

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.

Platform encounters: A study of digitised patient follow-up in HIV care

Digital technologies are increasingly embedded in clinical encounters, reconfiguring the basis on which health care is delivered. Thereby, the delivery of care shifts from territorial locations in clinics and temporal modes of co-presence towards digital platforms. Drawing on a sociotechnical evaluation of digitised patient follow-up in HIV care, this paper argues that the forms of interactivity practised in platform encounters cannot be adequately understood through traditional interaction frameworks such as Erving Goffman's interaction order. To conceptualise the new informational space and temporal mode of 'response presence' within which platform encounters are conducted, the paper draws on theoretical advances made by Karin Knorr Cetina who further developed Goffman's interaction order to describe interactions augmented by 'scopic media'. A comprehensive framework is presented to elaborate the distinct qualities of interactions occurring in face-to-face, tele-interaction and platform encounters and to analyse their affordances based on doctor and patient experiences. This framework is intended to stimulate further research on how new interactional forms between doctors and patients will reconfigure roles and responsibilities as well as wider structures of digital society. Furthermore, it can also support practical guidance of when and how different forms of clinical encounters may be integrated in care pathways.

Exploring Participants' Experiences of a Web-Based Program for Bulimia and Binge Eating Disorder: Qualitative Study

BACKGROUND

Guided cognitive behavioral self-help is a recommended first-line treatment for eating disorders (EDs) such as bulimia nervosa (BN) or binge eating disorder (BED). Online versions of such self-help programs are increasingly being studied in randomized controlled trials (RCTs), with some evidence that they can reduce ED symptoms, although intervention dropout is variable across interventions. However, in-depth research into participants' experiences and views on the acceptability of web-based interventions is limited.

OBJECTIVE

This is a qualitative process study of participants' experiences of everyBody Plus, a web-based cognitive behavioral intervention, integrated into a large RCT to aid the interpretation of the main trial's results. To our knowledge, this is the first such study in digital intervention for EDs research to include real-time feedback into the qualitative analysis. This study aims to build upon the emerging literature by qualitatively exploring participants' experiences of a web-based intervention for BN and BED.

METHODS

Participants were those who took part in the UK arm of a larger RCT investigating the efficacy of the everyBody Plus intervention. Reflexive thematic analysis was completed on 2 sources of data from the online platform: real-time feedback quotes provided at the end of completing a module on the platform (N=104) and semistructured telephone interview transcripts (n=12).

RESULTS

Four main themes were identified. The first theme identified positive and negative user experiences, with a desire for a more customized and personalized intervention. Another theme positively reflected on how flexible and easy the intervention was to embed into daily life, compared with the silo of face-to-face therapy. The third theme identified how the intervention had a holistic impact cognitively, emotionally, interpersonally, and behaviorally. The final theme was related to how the intervention was not a one size fits all and how the perceived usefulness and relevance were often dependent on participants' demographic and clinical characteristics.

CONCLUSIONS

Overall, participants reported positive experiences with the use of the everyBody Plus web-based intervention, including flexibility of use and the potential to holistically impact people's lives. The participants also provided valuable suggestions for how similar future web-based interventions could be improved and, in the context of EDs, how programs can be designed to be more inclusive of people by encompassing different demographic and clinical characteristics.

Use of virtual consultations in an orthopaedic rehabilitation setting: how do changes in the work of being a patient influence patient preferences? A systematic review and qualitative synthesis

OBJECTIVES

To systematically review qualitative studies reporting the use of virtual consultations within an orthopaedic rehabilitation setting and to understand how its use changes the work required of patients.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, we conducted a systematic review of papers to answer the research question 'How do changes in the work of being a patient when using communication technology influence patient preferences?' Electronic databases were searched for studies meeting the inclusion criteria in April 2020.

RESULTS

The search strategy identified 2057 research articles from the database search. A review of titles and abstracts using the inclusion criteria yielded 21 articles for full-text review. Nine studies were included in the final analysis. Six studies explored real-time video conferencing and three explored telephone consultations. The use of communication technology changes the work required of patients. Such changes will impact on expectations for care, resources required of patients, the environment of receiving care and patient-clinician interactions. This adjustment of the work required of patients who access orthopaedic rehabilitation using communication technology will impact on their experience of receiving care. It is proposed that changes in the work of being a patient will influence preferences for or against the use of communication technology consultations for orthopaedic rehabilitation.

CONCLUSION

We found that the use of communication technology changes the work of being a patient. The change in work required of patients can be both burdensome (it makes it harder for patients to access their care) and beneficial (it makes it easier for patients to access their care). This change will likely to influence preferences. Keeping the concept of patient work at the heart of pathway redesign is likely to be a key consideration to ensure successful implementation.

PROSPERO REGISTRATION NUMBER

CRD42018100896.

Round hole, square peg: a discourse analysis of social inequalities and the political legitimization of health technology in Norway

Background

As research increasingly investigates the impacts of technological innovations in health on social inequalities, political discourse often promotes development and adoption, limiting an understanding of unintended consequences. This study aimed to investigate national public health policy discourse focusing on innovative health technology and social inequalities, from a Norwegian context.

Methods

The analysis relies on a perspective inspired by critical discourse analysis using central State documents typically influential in the lawmaking procedure.

Results

The results and discussion focus on three major discourse strands: 1) ‘technologies discourse’ (types of technologies), 2) ‘responsibility discourse’ (who has responsibility for health and technology), 3) ‘legitimization discourse’ (how technologies are legitimized).

Conclusions

Results suggest that despite an overt political imperative for reducing social inequalities, the Norwegian national discourse gives little attention to the potential for these innovations to unintentionally (re) produce social inequalities. Instead, it is characterized by neoliberal undertones, individualizing and commercializing public health and promoting pro-innovation ideology.

Experiences of computer-based and conventional self-help interventions for eating disorders: A systematic review and meta-synthesis of qualitative research

OBJECTIVE

Self-help interventions have been demonstrated to be effective in treating bulimic-type eating disorders (EDs). In particular, computer-based interventions have received increasing attention due to their potential to reach a wider population. This systematic review aimed to synthesize findings from qualitative studies on users' experiences of self-help interventions for EDs and to develop an exploratory framework.

METHOD

A systematic review and meta-synthesis on seven peer-reviewed qualitative studies on structured computer and book-based self-help interventions for EDs was conducted using Noblit and Hare's (1988) 7-phase meta-ethnography. Four of the selected studies investigated computer-based self-help programs, and three of the studies investigated book-based guided self-help programs.

RESULTS

Six concepts were synthesized. They included intervention-related factors (anonymity and privacy; accessibility and flexibility; guidance) and user-related factors (agency/autonomy; self-motivation; and expectations/attitudes). The study revealed the "machine-like" and relational properties of the computer; the expansion of treatment time and space in psychological interventions, the changing role of the medical health professional from a "therapist" to a "guide," and a change from understanding interventions as a conclusive treatment plan to a starting point or stepping stone toward recovery.

DISCUSSION

Computer-based self-help interventions should take advantage of the "machine-like" properties of a computer (neutrality, availability, etc.) as well as its ability to facilitate human interactions. Users should also be facilitated to have a realistic understanding of the purpose of self-help interventions and the place of self-help interventions in their broader treatment plans to moderate expectations and attitudes.