A systematic scoping review of change management practices used for telemedicine service implementations

Long-Term Adoption of Televisits in Nursing Homes During the COVID-19 Crisis and Following Up Into the Postpandemic Setting: Mixed Methods Study

BACKGROUND

There is growing evidence that telemedicine can improve the access to and quality of health care for nursing home residents. However, it is still unclear how to best manage and guide the implementation process to ensure long-term adoption, especially in the context of a decline in telemedicine use after the COVID-19 crisis.

OBJECTIVE

This study aims to identify and address major challenges for the implementation of televisits among residents in a nursing home, their caring nurses, and their treating general practitioners (GPs). It also evaluated the impact of televisits on the nurses' workload and their nursing practice.

METHODS

A telemedical system with integrated medical devices was introduced in 2 nursing homes and their cooperating GP offices in rural Germany. The implementation process was closely monitored from the initial decision to introduce telemedicine in November 2019 to its long-term routine use until March 2023. Regular evaluation was based on a mixed methods approach combining rigorous qualitative approaches with quantitative measurements.

RESULTS

In the first phase during the COVID-19 pandemic, both nursing homes achieved short-term adoption. In the postpandemic phase, an action-oriented approach made it possible to identify barriers and take control actions for long-term adoption. The implementation of asynchronous visits, strong leadership, and sustained training of the nurses were critical elements in achieving long-term implementation in 1 nursing home. The implementation led to enhanced clinical skills, higher professional recognition, and less psychological distress among the nursing staff. Televisits resulted in a modest increase in time demands for the nursing staff compared to organizing in-person home visits with the GPs.

CONCLUSIONS

Focusing on health care workflow and change management aspects depending on the individual setting is of utmost importance to achieve successful long-term implementation of telemedicine.

Selection of criteria for a telemedicine framework for designing, implementing, monitoring and evaluating telemedicine interventions: Validation using a modified Delphi process

Objectives

The call to scale up telemedicine services globally as part of the digital health transformation lacks an agreed-upon set of constructs to guide the implementation process. A lack of guidance hinders the development, consolidation, sustainability and optimisation of telemedicine services. The study aims to reach consensus among telemedicine experts on a set of implementation constructs to be developed into an evidence-based support tool.

Methods

A modified Delphi study was conducted to evaluate a set of evidence-informed telemedicine implementation constructs comprising cores, domains and items. The study evaluated the constructs consisting of five cores: Assessment of the Current Situation, Development of a Telemedicine Strategy, Development of Organisational Changes, Development of a Telemedicine Service, and Monitoring, Evaluation and Optimisation of Telemedicine Implementation; seven domains: Individual Readiness, Organisational Readiness, Clinical, Economic, Technological and Infrastructure, Regulation, and Monitoring, Evaluation and Optimisation; divided into 53 items. Global telemedicine specialists (n = 247) were invited to participate and evaluate 58 questions. Consensus was set at ≥70%.

Results

Forty-five experts completed the survey. Consensus was reached on 78% of the constructs evaluated. Regarding the core constructs, Monitoring, Evaluation and Optimisation of Telemedicine Implementation was determined to be the most important one, and Development of a Telemedicine Strategy the least. As for the domains, the Clinical one had the highest level of consensus, and the Economic one had the lowest.

Conclusions

This research advances the field of telemedicine, providing expert consensus on a set of implementation constructs. The findings also highlight considerable divergence in expert opinion on the constructs of reimbursement and incentive mechanisms, resistance to change, and telemedicine champions. The lack of agreement on these constructs warrants attention and may partly explain the barriers that telemedicine services continue to face in the implementation process.

Telehealth Implementation Response to COVID-19 in the OneFlorida+ Clinical Research Network: Perspectives of Clinicians and Health Systems Leaders

Introduction: The COVID-19 pandemic forced health systems worldwide to make rapid adjustments to patient care. Nationwide stay-at-home mandates and public health concerns increased demand for telehealth to maintain patients' continuity of care. These circumstances permitted observation of telehealth implementation in real-world settings at a large scale. This study aimed to understand clinician and health system leader (HSL) experiences in expanding, implementing, and sustaining telehealth during COVID-19 in the OneFlorida+ clinical research network. Methods: We conducted semistructured videoconference interviews with 5 primary care providers, 7 specialist providers, and 12 HSLs across 7 OneFlorida+ health systems and settings. Interviews were audiorecorded, transcribed, and summarized using deductive team-based template coding. We then used matrix analysis to organize the qualitative data and identify inductive themes. Results: Rapid telehealth implementation occurred even among sites with low readiness, facilitated by responsive planning, shifts in resource allocation, and training. Common hurdles in routine telehealth use, including technical and reimbursement issues, were also barriers to telehealth implementation. Acceptability of telehealth was influenced by benefits such as the providers' ability to view a patient's home environment and the availability of tools to enhance patient education. Lower acceptability stemmed from the inability to conduct physical examinations during the shutdown. Conclusions: This study identified a broad range of barriers, facilitators, and strategies for implementing telehealth within large clinical research networks. The findings can contribute to optimizing the effectiveness of telehealth implementation in similar settings, and point toward promising directions for telehealth provider training to improve acceptability and promote sustainability.

Developing a Theoretically Informed Implementation Model for Telemedicine-Delivered Medication for Opioid Use Disorder: Qualitative Study With Key Informants

BACKGROUND

Telemedicine-delivered medication for opioid use disorder (TMOUD) has become more prevalent during the COVID-19 pandemic, particularly in North America. This is considered a positive development as TMOUD has the potential to increase access to evidence-based treatment for a population heavily affected by the opioid crisis and consequent rising mortality and morbidity rates in relation to opioid use disorder. Despite the increase in the use of TMOUD, there are no established service- and process-focused models to guide the implementation of this intervention.

OBJECTIVE

This study aims to develop a process- and service-focused implementation model in collaboration with key stakeholders and bring together peer-reviewed literature, practice-based knowledge, and expert opinions.

METHODS

The simple rules for evidence translation in complex systems framework was applied to guide the development of a 6-step qualitative study. The steps were definition of the scope and objectives of the model, identification of evidence, stakeholder engagement, draft model development, key informant consultation, and final model specification.

RESULTS

The final specification for the TMOUD implementation model incorporated key strategic priorities, service delivery prerequisites, service design elements, stakeholder identification and engagement, key process domains, and iterative cycles of evaluation and improvement.

CONCLUSIONS

Through stakeholder engagement and key informant consultation, we produced a process- and service-focused TMOUD implementation model. The model is modifiable to different contexts and settings while also in keeping with the current evidence base and national and international standards of high-quality opioid use disorder care.

Readiness for Change in the Implementation of a 3D Printing Initiative in a Catalan Tertiary Hospital Using the Normalization Process Theory: Survey Study

BACKGROUND

The high failure rate of innovation projects motivates us to understand the perceptions about resistances and barriers of the main stakeholders to improving success rates.

OBJECTIVE

This study aims to analyze the readiness for change in the implementation of a 3D printing project in a Catalan tertiary hospital prior to its implementation.

METHODS

We used a web-based, voluntary, and anonymous survey using the Normalization Measurement Development questionnaire (NoMAD) to gather views and perceptions from a selected group of health care professionals at Germans Trias i Pujol University Hospital.

RESULTS

In this study, 58 professionals, including heads of service (n=30, 51%), doctors (n=18, 31%), nurses (n=7, 12%), and support staff (n=3, 5%), responded to the questionnaire. All groups saw the value of the project and were willing to enroll and support it. Respondents reported the highest scores (out of 5) in cognitive participation (mean 4.45, SD 0.04), coherence (mean 3.72, SD 0.13), and reflective monitoring (mean 3.80, SD 0.25). The weakest score was in collective action (mean 3.52, SD 0.12). There were no statistically significant differences in scores among professions in the survey.

CONCLUSIONS

The 3D printing project implementation should pay attention to preparing, defining, sharing, and supporting the operational work involved in its use and implementation. It should also understand, assess, and communicate the ways in which the new set of practices can affect the users and others around them. We suggest that health officers and politicians consider this experience as a solid ground toward the development of a more efficient health innovation system and as a catalyst for transformation.

A comparison study between metropolitan and rural hospital-based telehealth activity to inform adoption and expansion

INTRODUCTION

In Queensland, Australia, the public hospital system has used telehealth for almost three decades. Although telehealth activity has been growing consistently, there are substantial variations across geographic regions. We explored factors which contribute to this variation in telehealth adoption.

METHODS

This was a multi-method comparative study of two matched metropolitan health services and two matched rural health services. The health services were matched according to the number of providers and hospitals but had different rates of telehealth use. Comparative rates of telehealth visits were analysed using descriptive statistics. Qualitative data was obtained from 63 semi-structured interviews with telehealth administrators, clinicians and senior managers involved in telehealth policies and procedures. Data were analysed using a framework analysis.

RESULTS

The metropolitan health service that had more telehealth use had greater investment in telehealth, higher population referral areas, highly developed communication strategies and understanding of the value proposition for telehealth, and reported fewer information technology and administration systems difficulties. In rural health services, telehealth activity was influenced by onboarding processes, clinician willingness to practice, strategic challenges and primary care activity.

DISCUSSION

Telehealth adoption can be influenced by funding, cross-organisational strategic policies and a multi-faceted approach to address clinician reluctance to use telehealth.

Innovative Projects: A Unique Approach to Telehealth Education

ABSTRACT

During the COVID-19 pandemic, telehealth utilization grew astronomically, encouraging more institutions of higher education to become innovative and proactive in preparing health care providers to deliver high-quality telehealth care. Telehealth can be creatively implemented throughout health care curricula given the appropriate guidance and tools. This article speaks to the development of student telehealth projects as part of the work of a national taskforce funded by the Health Resources and Services Administration and charged with the development of a telehealth toolkit. Proposed telehealth projects allow students to take the lead in their innovative learning and allow faculty to facilitate project-based evidence-based pedagogy.

Telehealth services for global emergencies: implications for COVID-19: a scoping review based on current evidence

INTRODUCTION

The availability of low-cost computing and digital telecommunication in the 1980s made telehealth practicable. Telehealth has the capacity to improve healthcare access and outcomes for patients while reducing healthcare costs across a wide range of health conditions and situations.

OBJECTIVE

This study compares the adoption, advantages, and challenges of telehealth services between high-income (HICs) and low-and-middle-income countries (LMICs) before and during the COVID-19 pandemic.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The key search terms were: "Telehealth", "Telehealth in HICs", "Telehealth in LMICs", "Telehealth before COVID-19", "Telehealth during COVID-19". We searched exhaustively ProQuest, Scopus, Web of Science, Google Scholar, CINAHL, and EMBASE databases from 2012. Booleans OR/AND were combined with key search terms to increase relevant search results. The literature search and selection process followed the Sample, Phenomena of Interest, Design, Evaluation, and Research (SPIDER) question format.

RESULTS

The adoption of telehealth before COVID-19 was generally low in both HICs and LMICs. The impact of COVID-19 accelerated the adoption of telehealth at the facility level but not nationwide in both high-income countries and LMICs. The rapid adoption of telehealth at the facility level in both high-income and LMICs introduced several challenges that are unique to each country and need to be addressed.

CONCLUSION

The lack of national policies and regulations is making the adoption of telehealth at the national level challenging in both high and low-middle-income countries. Governments and Stakeholders of healthcare must consider telehealth as a healthcare procedure that should be deployed in clinical working procedures. Primary quantitative and qualitative studies must be conducted to address challenges encountered during the pilot implementation of telehealth services in both high-income countries and LMICs before and during pandemics.

Telemedicine perceptions and experiences of socially vulnerable households during the early stages of the COVID-19 pandemic: a qualitative study

BACKGROUND

Early in the COVID-19 pandemic, efforts to decrease risk of viral transmission triggered an abrupt shift from ambulatory health care delivery toward telemedicine. In this study, we explore the perceptions and experiences of telemedicine among socially vulnerable households and suggest strategies to increase equity in telemedicine access.

METHODS

Conducted between August 2020 and February 2021, this exploratory qualitative study involved in-depth interviews with members of socially vulnerable households needing health care. Participants were recruited from a food bank and primary care practice in Montréal. Digitally recorded telephone interviews focused on experiences and perceptions related to telemedicine access and use. In our thematic analysis, we employed the framework method to facilitate comparison, and the identification of patterns and themes.

RESULTS

Twenty-nine participants were interviewed, 48% of whom presented as women. Almost all sought health care in the early stages of the pandemic, 69% of which was received via telemedicine. Four themes emerged from the analysis: delays in seeking health care owing to competing priorities and perceptions that COVID-19-related health care took precedence; challenges with appointment booking and logistics given complex online systems, administrative inefficiencies, long wait times and missed calls; issues around quality and continuity of care; and conditional acceptance of telemedicine for certain health problems, and in exceptional circumstances.

INTERPRETATION

Early in the pandemic, participants report telemedicine delivery did not accommodate the diverse needs and capacities of socially vulnerable populations. Patient education, logistical support and care delivery by a trusted provider are suggested solutions, in addition to policies supporting digital equity and quality standards to promote telemedicine access and appropriate use.

Ethical, Legal, Organisational and Social Issues of Teleneurology: A Scoping Review

BACKGROUND

Neurological disorders are the leading cause of disability and the second leading cause of death worldwide. Teleneurology (TN) allows neurology to be applied when the doctor and patient are not present in the same place, and sometimes not at the same time. In February 2021, the Spanish Ministry of Health requested a health technology assessment report on the implementation of TN as a complement to face-to-face neurological care.

METHODS

A scoping review was conducted to answer the question on the ethical, legal, social, organisational, patient (ELSI) and environmental impact of TN. The assessment of these aspects was carried out by adapting the EUnetHTA Core Model 3.0 framework, the criteria established by the Spanish Network of Health Technology Assessment Agencies and the analysis criteria of the European Validate (VALues In Doing Assessments of healthcare TEchnologies) project. Key stakeholders were invited to discuss their concerns about TN in an online meeting. Subsequently, the following electronic databases were consulted from 2016 to 10 June 2021: MEDLINE and EMBASE.

RESULTS

79 studies met the inclusion criteria. This scoping review includes 37 studies related to acceptability and equity, 15 studies developed during COVID and 1 study on environmental aspects. Overall, the reported results reaffirm the necessary complementarity of TN with the usual face-to-face care.

CONCLUSIONS

This need for complementarity relates to factors such as acceptability, feasibility, risk of dehumanisation and aspects related to privacy and the confidentiality of sensitive data.

Barriers and facilitators to the adoption of digital health interventions for COPD management: A scoping review

BACKGROUND

Knowledge of the barriers and facilitators in the adoption of digital health interventions (DHI) is sparse yet crucial to facilitate chronic obstructive pulmonary disease (COPD) management.

OBJECTIVES

This scoping review aimed to summarize patient- and healthcare provider-level barriers and facilitators in the adoption of DHIs for COPD management.

METHODS

Nine electronic databases were searched from inception up till October 2022 for English language evidence. Inductive content analysis was used.

RESULTS

This review included 27 papers. Frequent patient-level barriers were poor digital literacy (n = 6), impersonal care delivery (n = 4), and fear of being controlled by telemonitoring data (n = 4). Frequent patient-level facilitators were improved disease understanding and management (n = 17), bi-directional communication and contact with healthcare providers (n = 15), and remote monitoring and feedback (n = 14). Frequent healthcare provider-level barriers were increased workload (n = 5), lack of technology interoperability with existing health systems (n = 4), lack of funding (n = 4), and lack of dedicated and trained manpower (n = 4). Frequent healthcare provider-level facilitators were improved efficiency of care delivery (n = 6) and DHI training programmes (n = 5).

CONCLUSION

DHIs have the potential to facilitate COPD self-management and improve efficiency of care delivery. However, several barriers challenge its successful adoption. Attaining organizational support in developing user centric DHIs that can be integrated and are interoperable with existing health systems is crucial if we are to witness tangible return on investments at the patient-, healthcare provider- and healthcare system-level.

Menopause care delivery in the time of COVID-19: evaluating the acceptability of telehealth services for women with early and usual age menopause

OBJECTIVES

This study aimed to explore women's and clinician's experiences and acceptability of telehealth use within a specialized multidisciplinary menopause service during the COVID-19 pandemic.

METHODS

In-depth qualitative semi-structured interviews were analyzed via thematic inductive approaches. Telehealth acceptability was guided by the Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies (NASSS) framework.

RESULTS

A heterogeneous group of 18 women who had attended the menopause service and six clinicians (gynecologists and endocrinologists) were interviewed. The majority of women and clinicians perceived telehealth as an acceptable way to deliver menopause care. Benefits of telehealth delivery were identified; themes centered around convenience, greater access to care and improved safety. Telehealth challenges included perceived impacts on personalized quality of care, patient-related logistical issues and system/organizational-related issues. A hybrid flexible delivery model combining telehealth and face-to-face care was recommended, following the easing of COVID-19 restrictions. Improvements to support embedding and adaptation of telehealth into routine care were described.

CONCLUSION

In this study, telehealth was viewed as acceptable, supporting the ongoing delivery of a hybrid service model of telehealth and face-to-face menopause care. The findings provide valuable information to improve the menopause service to meet the needs of women during the ongoing current pandemic and beyond.

Knowledge, attitudes and practices of healthcare professionals on the use of an electronic stock visibility and management tool in a middle-income country: Implications for access to medicines

Background

The Stock Visibility System (SVS) is a mobile application and web-based management tool used at public primary health care (PHC) facilities in South Africa to capture and monitor medicines availability, providing visibility at national level. Medicine stock-outs are prevalent despite the implementation of SVS, compromising patient care. This study aimed to assess the knowledge, attitudes and practices (KAP) of healthcare professionals (HCPs) on the use of the SVS at PHC level to provide future guidance.

Method

A cross-sectional study using a structured self-administered questionnaire among 206 HCPs at 21 randomly selected PHC facilities located in a health district in KwaZulu-Natal Province, South Africa. Closed-ended questions were used to collect data on socio-demographic characteristics, knowledge on the SVS and practices on its use. A Likert scale was used to determine attitudes towards the SVS. Cronbach's alpha (α) was used to assess the internal consistency of the questionnaire and independent samples t-test and one-way analysis of variance (ANOVA) was used to test statistical difference in the mean scores for KAP and socio-demographic variables. Association between knowledge and practices, and attitude and practices was determined using odds ratios (OR) and Chi-square.

Results

The majority (99.5%) of HCPs had previous training on SVS. Nearly two thirds (62.1%; 128/206) generally had good knowledge about the SVS and 76.7% (158/206) had positive attitudes towards the SVS while only 17.0% had a good practice score. There was no statistically significant association between KAP of HCPs on the use of the SVS, and sociodemographic variables (HCP qualification, age and sex). There was a significant association between the knowledge and practice scores (aOR: 5.44; 95% CI: 1.92-15.4; p = 0.001). Although positive attitudes, was associated with good practices, it was not statistically significant (OR: 1.21; 95% CI: 0.46-3.22; p = 0.702).

Conclusions

HCPs in this district had poor practices when using SVS despite good knowledge and positive attitudes towards SVS and the higher the HCPs knowledge of SVS, the more desirable the practices on SVS. This underscores the need for continuous training of HCPs to ensure a constant and efficient supply of medicines to meet the health needs of the population.

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review

BACKGROUND

Long-term sustained improvement following implementation of hospital-wide quality and safety initiatives is not easily achieved. Comprehensive theoretical and practical understanding of how gained improvements can be sustained to benefit safe and high-quality care is needed. This review aimed to identify enabling and hindering factors and their contributions to improvement sustainability from hospital-wide change to enhance patient safety and quality.

METHODS

A systematic scoping review method was used. Searched were peer-reviewed published records on PubMed, Scopus, World of Science, CINAHL, Health Business Elite, Health Policy Reference Centre and Cochrane Library and grey literature. Review inclusion criteria included contemporary (2010 and onwards), empirical factors to improvement sustainability evaluated after the active implementation, hospital(s) based in the western Organisation for Economic Co-operation and Development countries. Numerical and thematic analyses were undertaken.

RESULTS

17 peer-reviewed papers were reviewed. Improvement and implementation approaches were predominantly adopted to guide change. Less than 6 in 10 (53%) of reviewed papers included a guiding framework/model, none with a demonstrated focus on improvement sustainability. With an evaluation time point of 4.3 years on average, 62 factors to improvement sustainability were identified and emerged into three overarching themes: People, Process and Organisational Environment. These entailed, as subthemes, actors and their roles; planning, execution and maintenance of change; and internal contexts that enabled sustainability. Well-coordinated change delivery, customised local integration and continued change effort were three most critical elements. Mechanisms between identified factors emerged in the forms of Influence and Action towards sustained improvement.

CONCLUSIONS

The findings map contemporary empirical factors and their mechanisms towards change sustainability from a hospital-wide initiative to improve patient safety and quality. The identified factors and mechanisms extend current theoretical and empirical knowledgebases of sustaining improvement particularly with those beyond the active implementation. The provided conceptual framework offers an empirically evidenced and actionable guide to assist sustainable organisational change in hospital settings.

Prioritising enhancements across allied health telehealth services in a metropolitan hospital: Using a concept mapping approach

Introduction

A prior study examining perceptions of Allied Health Professions (AHP) telehealth services at a metropolitan hospital highlighted multiple issues impacting service uptake, operationalisation, and delivery. Concept mapping methodology was utilised to address these issues and prioritise actionable telehealth service improvements.

Methods

Representatives ( n = 22) from seven AHP departments and consumers generated statements addressing the question: ‘What do we need to do to enhance and sustain telehealth services?’ Statements were synthesised and then clinicians and managers sorted them into similar groups and assigned each statement a ranking of perceived (a) importance and (b) changeability. Multivariate and multidimensional scaling was undertaken to develop a final prioritised set of goals for change.

Results

Ninety-six unique statements were generated as actionable goals for change. Statements were grouped into 13 clusters relating to improvements in staff support, infrastructure, consumer support and organisational processes. All clusters were rated >50% for importance (range 3.3–2.4 out of 4) and changeability (range 2.6–2.1 out of 4). Twenty-six statements were ranked highest for importance and changeability. Key prioritised areas were staff training, consumer advocacy and engagement, telehealth operations and workflow.

Conclusion

Concept mapping was an effective process for generating a prioritised list of actions to enhance AHP telehealth services.

A scoping review of applications of the Consolidated Framework for Implementation Research (CFIR) to telehealth service implementation initiatives

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR), introduced in 2009, has the potential to provide a comprehensive understanding of the determinants of implementation-effectiveness of health service innovations. Although the CFIR has been increasingly used in recent years to examine factors influencing telehealth implementation, no comprehensive reviews currently exist on the scope of knowledge gained exclusively from applications of the CFIR to telehealth implementation initiatives. This review sought to address this gap.

METHODS

PRISMA-ScR criteria were used to inform a scoping review of the literature. Five academic databases (PUBMED, PROQUEST, SCIDIRECT, CINAHL, and WoS) were searched for eligible sources of evidence from 01.01.2010 through 12.31.2021. The initial search yielded a total of 18,388 records, of which, 64 peer-reviewed articles met the inclusion criteria for the review. Included articles were reviewed in full to extract data, and data collected were synthesized to address the review questions.

RESULTS

Most included articles were published during or after 2020 (64%), and a majority (77%) were qualitative or mixed-method studies seeking to understand barriers or facilitators to telehealth implementation using the CFIR. There were few comparative- or implementation-effectiveness studies containing outcome measures (5%). The database search however, revealed a growing number of protocols for implementation-effectiveness studies published since 2020. Most articles (91%) reported the CFIR Inner Setting domain (e.g., leadership engagement) to have a predominant influence over telehealth implementation success. By comparison, few articles (14%) reported the CFIR Outer Setting domain (e.g., telehealth policies) to have notable influence. While more (63%) telehealth initiatives were focused on specialty (vs primary) care, a vast majority (78%) were focused on clinical practice over medical education, healthcare administration, or population health.

CONCLUSIONS

Organized provider groups have historically paid considerable attention to advocating for telehealth policy (Outer Setting) reform. However, results suggest that for effective telehealth implementation, provider groups need to refocus their efforts on educating individual providers on the complex inter-relationships between Inner Setting constructs and telehealth implementation-effectiveness. On a separate note, the growth in implementation-effectiveness study protocols since 2020, suggests that additional outcome measures may soon be available, to provide a more nuanced understanding of the determinants of effective telehealth implementation based on the CFIR domains and constructs.

Use of Teletherapy for allied health interventions in community-based disability services: A scoping review of user perspectives

Understanding the experiences and perspectives of users of teletherapy living with a disability and working with them, offers the potential to improve its capacity to meet their requirements. Literature examining the effectiveness of interventions delivered via teletherapy often fail to explore the motivators and implementation needs of the users. The scoping review aimed to examine the research evidence addressing user perspectives of teletherapy in delivery of allied health interventions to the disability community. The Joanna Briggs scoping review protocol methodology was employed with searches completed across five databases (ProQuest, CINAHL (EBSCO), Medline (OVID), Scopus, Google Scholar) in September 2021. The search yielded a total of 1365 results, 147 progressed to full text screening and 22 articles included in thematic analysis. Findings were split into themes addressing organisational and implementation based considerations for teletherapy, and secondly the social and contextual considerations of the Target Participants. The two areas of interest were addressed under each theme some of which include resourcing and upskilling, financial, challenging the status quo, moving from hands on to coaching and the utilisation of a hybrid model of intervention delivery. Teletherapy is viewed as creating a distinct set of benefits and challenges compared to in person service delivery, which impact individual members of the disability community differently. The scoping review identifies a strong need from recipients to trial teletherapy and experience it personally to facilitate understanding of how it can best suit an individual. More than being viewed as an alternative to in person services, teletherapy is viewed by users as better suited as a complementary service with flexibility of hybrid model opportunities valued above exclusive use of one over the other.

A qualitative research study of primary care physicians' views of telehealth in delivering postnatal care to women

BACKGROUND

The postpartum period is a critical time for women to optimise their physical and mental health. Primary care physicians (PCP) often manage postpartum women in the community setting after uneventful births. However, women encounter difficulties accessing care before and after their conventional 6-week physical review. Telehealth-based interventional studies have demonstrated their successful applications in several areas of postpartum care but is not widely adopted. The study aimed to explore the PCPs' views on their acceptability and perceived barriers of telehealth in delivering postpartum care to women in primary care.

METHODS

Twenty-nine PCPs participated in eleven in-depth interviews and four focus group discussions for this qualitative study conducted in Singapore. The purposively sampled PCPs had varied demographic background and medical training. Two investigators independently coded the audited transcripts. Thematic content analysis was performed using the codes to identify issues in the pertaining to the perceived usefulness, ease of use and attitudes towards telehealth in postpartum care as described in the "Telehealth Acceptance Model" framework.

RESULTS

Most PCPs perceived usefulness and ease of use of video consultation in delivering postpartum care. They recognised telehealth service to complement and support the current face-to-face postpartum care amidst the pandemic. However, training, leadership support, organizational infrastructure, healthcare financial policy and personal demographic profile influence their acceptance of a new care model for postnatal mothers.

CONCLUSION

Addressing the barriers and strengthening the facilitators will enhance PCPs' acceptance and utilisation of the proposed hybrid (telehealth and in-person) postnatal care model for mothers.

Implementation of a telemedicine, stroke evaluation service; a qualitative study

Background

Acute ischemic stroke requires early medical imaging with a computed tomography (CT) scan and immediate thrombolysis treatment. In rural areas, the long distance to the nearest hospital reduce the patients’ probability of receiving medical assistance within the 4.5-h period. The aim of this study was to assess how the service was set-up, and how managers and personnel experience the organisation and value of a rural telemedicine, remote controlled CT stroke service.

Methods

Ten semi-structured individual interviews and one semi-structured focus group interview were conducted. The sample included 15 participants involved in the telemedicine service in Hallingdal, Norway. The interview guide consisted of questions on the service, experience of working with the service, value and quality, management, and challenges. Interviews were recorded and transcribed verbatim. Thematic content analysis was used to develop a narrative of the findings.

Results

Findings were categorised into three main categories; value of the service, organisation of the project, and from project to permanent service. Participants perceived the service to be valuable for patients and the local community. The service included task shifting from radiographers and junior doctors to the local paramedics. To enable long- term operation of the service the participants suggested management, coordination, and continuous training as important factors.

Conclusions

The service was perceived as valuable to the local community, providing a sense of healthcare security and equitability. Management’s involvement, flexibility, and coordination appears to be a key factor for successful implementation and long-term sustainability of the service.

Effectiveness of Telemedicine Visits in Reducing 30-Day Readmissions Among Patients With Heart Failure During the COVID-19 Pandemic

Background

The COVID‐19 pandemic resulted in a rapid implementation of telemedicine into clinical practice. This study examined whether early outpatient follow‐up via telemedicine is as effective as in‐person visits for reducing 30‐day readmissions in patients with heart failure.

Methods and Results

Using electronic health records from a large health system, we included patients with heart failure living in North Carolina (N=6918) who were hospitalized between March 16, 2020 and March 14, 2021. All‐cause readmission within 30 days after discharge was examined using weighted logistic regression models. Overall, 7.6% (N=526) of patients received early telemedicine follow‐up, 38.8% (N=2681) received early in‐person follow‐up, and 53.6% (N=3711) did not receive follow‐up within 14 days of discharge. Compared with patients without early follow‐up, those who received early follow‐up were younger, were more likely to be Medicare beneficiaries, had more comorbidities, and were less likely to live in an disadvantaged neighborhood. Relative to in‐person visits, those with telemedicine follow‐up were of similar age, sex, and race but with generally fewer comorbidities. Overall, the 30‐day readmission rate (19.0%) varied among patients who received telemedicine visits (15.0%), in‐person visits (14.0%), or no follow‐up (23.1%). After covariate adjustment, patients who received either telemedicine (odds ratio [OR], 0.55; 95% CI, 0.44–0.72) or in‐person (OR, 0.52; 95% CI, 0.45–0.60) visits were similarly less likely to be readmitted within 30 days compared with patients with no follow‐up.

Conclusions

During the COVID‐19 pandemic, the use of telemedicine visits for early follow‐up increased rapidly. Patients with heart failure who received outpatient follow‐up either via telemedicine or in‐person had better outcomes than those who received no follow‐up.

Still engaged – healthcare staff’s engagement when introducing a new eHealth solution for wound management: a qualitative study

Background

eHealth solutions have often been considered favourable for improved effectiveness and quality in healthcare services for wound management. Staff engagement related to organisational changes is a key factor for successful development and implementation of a new eHealth solution, like a digital decision support systems (DDSS). It is essential to understand the engagement process in terms of sustainability, wellbeing in staff and efficiency in a long-term perspective. The aim of this study was to describe healthcare staff’s engagement during a 6-month test of an eHealth solution (DDSS) for wound management.

Methods

A qualitative design, including interviews conducted with healthcare staff working with wound management within primary, community and specialist care (n = 11) on two occasions: at the introduction of the solution and after 6 months, when the test period was over. Data were interpreted with qualitative content analysis.

Results

Healthcare staff’s descriptions from a 6-month test of an eHealth solution for wound management can be summarised as Engaging through meaning, but draining. The analysis revealed a result with three subcategories: Having a shared interest is stimulating, Good but not perfect and Exciting, but sometimes exhausting. The staff described their engagement as sustained through feelings of meaningfulness when using the eHealth solution, but limited by feelings of exhaustion due to heavy workload and lack of support and understanding from others.

Conclusions

The results indicate that the healthcare staff who tested the eHealth solution described themselves as individuals who easily become engaged when an idea and efforts felt meaningful. The staff needed resources to nourish engagement in their new role when implementing eHealth in the clinical everyday work of wound management. Allocating time and support are important to consider when planning for sustainable implementation of eHealth solutions in healthcare organisations.

Modifying UTAUT2 for a cross-country comparison of telemedicine adoption

The ongoing COVID19 pandemic has put digital health technologies in the spotlight. To gain a deeper understanding of patients’ usage intentions of virtual doctor appointments, the present research adapts the Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) by integrating perceived security and perceived product advantage, two known barriers to successful telemedicine adoption. Applying age-stratified sampling, an online survey was distributed to 800 citizens in Germany and the United States of America. 710 completed and valid questionnaires were subsequently analyzed using SPSS and AMOS (versions 24).

Significant, direct, and positive effects of performance expectancy, hedonic motivation, perceived security, and perceived product advantage on the behavioral intention to use virtual doctor appointments were found. The analysis of the moderating variables, age and gender, showed significant differences in user's performance expectancy and effort expectancy, and perceived product advantage, respectively. With virtual health care models on the rise, these results are important for stakeholders such as policymakers, governments, employers, but also physicians, and insurance companies as they offer clear recommendations to design telemedicine adoption strategies to ensure successful patient engagement.

Care providers’ experiences with and attitudes towards virtual antenatal care: Findings from a qualitative study in British Columbia

Background

Virtual care has emerged as an adjunctive response to challenges in rural health care, including maternity care, and use has accelerated during the coronavirus disease 2019 (COVID-19) pandemic. This gives rise to the need for a strategic plan for post-COVID-19 virtual maternity care in rural communities. To date, no provincial initiative has focused on understanding and documenting the needs of maternity care practitioners to provide virtual care.

Methods

Qualitative study, including virtual interviews and focus groups with rural primary maternity care providers and urban and rural specialists on perceptions of the utility of virtual maternity care pre- and post-COVID-19, and benefits and barriers of virtual care. Data were thematically analysed.

Results

In total, 82 health care providers participated in the study. Health care provider responses fell into three categories: Attributes of virtual care, barriers to virtual care and system interventions needed to optimize the provision of virtual perinatal care. Participants expressed a desire for use of virtual communication tools post-COVID-19, continued ability to use fee codes for virtual care and a need for more secure texting options. The benefits of tripartite consultations were noted by many participants; impacts of the transition to virtual care included additional workload and interrupted workflow. Concerns over the lack of physical examinations and challenges in building relationships with patients when providing virtual care were frequently noted.

Conclusion

Adapting the current implementation of virtual maternity care in British Columbia may be enhanced through several provider- and evidence-derived strategies, many of which are currently underway in BC. The results from this provincial survey will be used to focus further discussion on the characteristics of an optimal system to meet patient and provider needs within a rural context.

Determining factors that influence parents' perceptions of telehealth provided in a pediatric gastroenterological practice: A quality improvement project

BACKGROUND

In response to the COVID-19 pandemic, local and institutional guidelines restricted non-emergent, in-person visits in outpatient specialty clinics. Nurse practitioners (NPs) in pediatric gastroenterology clinics immediately shifted their practice to telehealth (TH).

LOCAL PROBLEM

The shift to TH necessitated a change in practice. This quality improvement project was designed to define factors influencing family's perceptions of TH and secure feedback on the TH experience. TH is remaining an option for accessing care even as restrictions are being lifted. Feedback is necessary to ensure that quality of care and high patient satisfaction are maintained in a virtual environment.

METHODS

The Unified Theory of Acceptance and Use of Technology was used to frame the project. Surveys were collected from NPs related to services provided and complexities of each encounter. Post-visit surveys were conducted with families to assess their perceptions of the visit. Findings were discussed to identify and address gaps in service.

RESULTS

Parent/family surveys were consistent with NP feedback. Results indicated that parents were satisfied with care provided via TH, but that these visits were limited by incomplete assessments, lacked the intimacy of in-person encounters and were often difficult to access due to technological issues.

CONCLUSIONS

It is anticipated that TH will be used in the post pandemic era to provide routine and non-emergent acute care. Institutions and providers need to consider factors influencing the patient experience learned during the pandemic and implement evidenced-based strategies that ensure quality care that meets patients' needs.

Sustaining allied health telehealth services beyond the rapid response to COVID-19: Learning from patient and staff experiences at a large quaternary hospital

The patient, clinician and administration staff perspectives of telehealth (specifically videoconferencing) services provided by Allied Health Professions (AHP) at a large quaternary hospital were explored. The purpose was to understand stakeholders' perceptions of the service during initial COVID-19 restrictions and examine factors that influenced the implementation and sustained use of telehealth. A sequential mixed-methods approach was undertaken. Stage 1 involved surveys completed by patients (n = 109) and clinicians (n = 66) who received and provided care via telehealth, respectively, across six AHP departments. Stage 2 involved focus groups with clinicians (n = 24) and administrative staff (n = 13) to further examine implementation and sustainability factors.All participant groups confirmed that telehealth was a valid service model and valued the benefits it afforded, particularly during COVID-19 restrictions. Both patients and clinicians reported that not all AHP services could be delivered via telehealth and preferred a blended model of telehealth and in-person care. Increased administrative staff assistance was needed to support growing telehealth demand. Main factors to address are the need to expand AHP telehealth models and workforce/patient training, improve workflow processes and enhance technical support.Despite rapid implementation, telehealth experiences were overall positive. Study findings are being used to generate solutions to enhance and sustain AHP telehealth services.

Considerations for the Implementation of a Telestroke Network: A Systematic Review

The application of telestroke has matured considerably since its inception in 1999. The use of telestroke is now recommended in several published guidelines. Consequently, jurisdictions without a telestroke service are seeking practical information on the best approach to implement telestroke. French et al. (2013) reviewed the challenges of implementing a telestroke network including studies between 2000 and 2010. At the time, telestroke networks were largely limited to the UK, USA, Canada and Europe and only one process evaluation had been conducted. Given the prolific expansion of telestroke services since 2010, we conducted a systematic review to determine factors associated with successful establishment, management, and sustainability of a contemporary telestroke services. A comprehensive search of telestroke studies was conducted in July 2021. Empirical studies published between 2010 and 2021 were included if they contained descriptive, evaluation or operational data on the implementation of a telestroke network. Studies were subsequently evaluated using the Consolidated Framework for Implementation Research (CFIR). The initial literature search revealed a total of 7415 potential studies; 38 of which met the inclusion criteria. The past decade of process evaluation studies has enabled a more nuanced investigations into how to implement and sustain a telestroke network. Pre-implementation planning is crucial to ensure clear telestroke processes, governance structures and stakeholder engagement. Sustainability of networks relies on securing long-term investment, providing adequate resources, and maintaining staff motivation and willingness. Recommendations are provided to overcome commonly identified barriers related to technology, staffing, planning and standardisation of processes, evaluation, and sustainability and scale-up. Further research needs to explore how new advancements in stroke care such as endovascular clot retrieval (EVT) and advanced brain imaging can be considered and planned for during the implementation of a new telestroke service.

Patients’ assessment of medical services quality – a determinant of changes in medical entity management on the example of Poland

Purpose

The article’s primary goal is to identify areas requiring improvement in the activities of healthcare entities, suggest directions for future changes, and indicate the strengths and weaknesses of the clinic’s operation based on patients’ opinions. Subjectively expressed opinions of patients are treated as acceptance of the current state of affairs or the need to introduce changes in a given area.

Design/methodology/approach

The empirical research was based on information obtained from questionnaire surveys on patients’ opinions about services provided by medical entities. The hypothesis was verified by research conducted in 23 (out of 50 possible) the most dynamically developing non-public healthcare institutions in one of the regions of Poland. The conducted research was based on a proprietary survey using questions on qualitative and quantitative scales.

Findings

The results of empirical research allowed us to identify areas requiring improvement and to propose future directions of changes in the surveyed units. The suggested changes should significantly improve efficiency in the organisation and management of a health facility, focused on medical effectiveness and patients’ health effectiveness.

Originality/value

From a broader perspective, research results may become a starting point for further considerations on changes in the organisation and management of healthcare facilities. Using the study’s conclusions in practice may positively affect the improvement of the functioning of healthcare facilities, their better reputation and contribute to increasing competitiveness in the medical services market.

E-Health Practices and Technologies: A Systematic Review from 2014 to 2019

E-health can be defined as a set of technologies applied with the help of the internet, in which healthcare services are provided to improve quality of life and facilitate healthcare delivery. As there is a lack of similar studies on the topic, this analysis uses a systematic literature review of articles published from 2014 to 2019 to identify the most common e-health practices used worldwide, as well as the main services provided, diseases treated, and the associated technologies that assist in e-health practices. Some of the key results were the identification of the four most common practices used (mhealth or mobile health; telehealth or telemedicine; technology; and others) and the most widely used technologies associated with e-health (IoT, cloud computing, Big Data, security, and systems).

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.With this review, we aim to (1) depict today's pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic

OBJECTIVE

This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth.

METHOD

A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers.

RESULTS

Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients.

CONCLUSION

The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

Development, Status Quo, and Challenges to China's Health Informatization During COVID-19: Evaluation and Recommendations

By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China's health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China's health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China's health informatization from five perspectives-health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system-and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China's policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China's current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China's health informatization. China's rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China's health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.

A Narrative Review of Factors Historically Influencing Telehealth Use across Six Medical Specialties in the United States

Prior to the COVID-19 pandemic, studies in the US have identified wide variations in telehealth use across medical specialties. This is an intriguing problem, because the US has historically lacked a standardized set of telehealth coverage and reimbursement policies, which has posed a barrier to telehealth use across all specialties. Although all medical specialties in the US have been affected by these macro (policy-level) barriers, some specialties have been able to integrate telehealth use into mainstream practice, while others are just gaining momentum with telehealth during COVID-19. Although the temporary removal of policy (coverage) restrictions during the pandemic has accelerated telehealth use, uncertainties remain regarding future telehealth sustainability. Since macro (policy-level) factors by themselves do not serve to explain the variation in telehealth use across specialties, it would be important to examine meso (organizational-level) and micro (individual-level) factors historically influencing telehealth use across specialties, to understand underlying reasons for variation and identify implications for widespread sustainability. This paper draws upon the existing literature to develop a conceptual framework on macro-meso-micro factors influencing telehealth use within a medical specialty. The framework is then used to guide a narrative review of the telehealth literature across six medical specialties, including three specialties with lower telehealth use (allergy-immunology, family medicine, gastroenterology) and three with higher telehealth use (psychiatry, cardiology, radiology) in the US, in order to synthesize themes and gain insights into barriers and facilitators to telehealth use. In doing so, this review addresses a gap in the literature and provides a foundation for future research. Importantly, it helps to identify implications for ensuring widespread sustainability of telehealth use in the post-pandemic future.

Understanding Telemedicine's "New Normal": Variations in Telemedicine Use by Specialty Line and Patient Demographics

Background:Our objective was to examine the variation in telemedicine adoption by specialty line and patient demographic characteristics after the initial peak period of the coronavirus disease 2019 pandemic when in-person visits had resumed and visit volume returned to prepandemic levels.

Materials and Methods:Aggregated encounter data were extracted for six service lines (dermatology, psychiatry, endocrinology, cardiology, orthopedics, and nonurgent primary care) in an integrated health system across three time periods: July 1 to September 30, 2019 (n = 239,803), July 1 to September 30, 2020 (n = 245,648), and December 29, 2019 to October 3, 2020 (n = 624,886). Risk ratios were calculated to assess the relative use of telemedicine compared with in-person encounters and telemedicine modality (i.e., synchronous audio/video vs. audio-only telephone) by patient race, age, sex, and insurance type.

Results:By June 2020, total visit volume returned to prepandemic levels. Differences in patient demographics between July 1 to September 30, 2020 and the previous year's baseline were negligible. Telemedicine adoption varied by medical specialty, from 3.2% (dermatology) to 98.3% (psychiatry) of visits. African American and male patients were less likely to use telemedicine (telephone or video) compared with white and female patients. Among telemedicine encounters, African American, publicly insured, and older patients were less likely to use video compared with white, commercially insured, and younger patients.

Discussion:Variation in telemedicine adoption and modality underscores the importance of balancing patient- and clinic-level implementation factors to promote sustainable, equitable telemedicine integration.

Conclusion:Understanding current trends in the “new normal” of telemedicine provides valuable insights into future implementation and financing.

Evaluating the Readiness of Mobile Technology with Respect to e-Heath for Medication in Saudi Arabia: An Integrative Perspective

Objective

The objective of this study was to evaluate the readiness of Saudi Arabian patients towards the adoption of the e-health system through the use of mobile phones.

Methods

In this research, a cross-sectional survey was carried out using a self-administered structured questionnaire. According to the results, 354 people viewed the questionnaire and 129 respondents were selected to assess the adoption of the e-health system in Saudi Arabia. The data were collected during February–March 2020.

Results

More than half of the respondents (63.6%) were women and almost half of the participants (48.0%) were married. Most of the surveyed patients suffered from cardiovascular diseases and diabetes. Almost all the participants (99.0%) had their personal mobile phone and used the Internet on these devices. Most of the participants did not trust or believe in online health services or online medical consultations and did not spend money on contracting health services through mobile phones. It is suggested that the lack of motivation to adopt the e-health system may be due to fear of privacy violations, fear of loss of personal data and information, lack of technical support, and mistrust in doctors who frequently use their cell phones to distract themselves during work-hours.

Conclusion

The results of this study revealed that the population of Saudi Arabia is reluctant to adopt the electronic e-health system promoted in the Saudi Vision 2030 strategic plan. To change this behavior, it is necessary to develop awareness campaigns and strategies that suggest the importance of using e-heath in the Saudi Arabian healthcare system. Additionally, it is essential that the network administrator implement procedures to protect the confidentiality and security of patients’ medical records.