Involving Citizen-Patients in the Development of Telehealth Services: Qualitative Study of Experts' and Citizen-Patients' Perspectives

The paradoxes of telehealth platforms: what did we learn from the use of telehealth platforms?

This article is an overview and reflection of the findings of an evaluative study conducted on a program called "Techno-Covid Partnership" (TCP) implemented in April 2020 at the Centre Hospitalier de l'Université de Montréal (CHUM) in Montreal, Canada. In the context of the COVID-19 pandemic, the CHUM decided in April 2020 to implement telehealth, virtual care, and telemonitoring platforms and technologies to maintain access to care and reduce the risks of contamination and spread of COVID-19 as well as to protect users of health services and health professionals. Three technological platforms for telehealth and remote care and monitoring have been developed, implemented, and evaluated in real-time within the framework of the TCP program. A cross-sectional study was carried out in which a questionnaire was used and administered to users of telehealth platforms including patients and healthcare professionals. The methods and results of the study have been published previously published. In the completion of the two articles published in this context, in this paper, we briefly recall the context of the study and the method performed. The main focus of the paper is on presenting a critical overview and reflection on the major findings of our evaluation of the use of telehealth platforms from the point of view of patients and health professionals and discuss certain paradoxes i.e., the advantages, challenges, recommendations, and other perspectives that emerged in this study.

Innovation through participatory design: Collaborative qualitative methods in the development of speech-language pathology technology

Speech-language pathologists have embraced many aspects of technology in their practice, from telehealth to tablet device applications (apps) that support intervention practice. In this article, we consider the design, development, and implementation of technology. We discuss how some processes of technology development in Speech-language pathology (SLP) tend to follow research pathways which centre clinicians and researchers as designers of the intervention. This approach side-lines user involvement. We propose that a Participatory Design framework is a suitable way to reconceptualise design and development of these technological innovations in a client-centred way. Further, we explore how Participatory Design approaches utilise methods from and have much in common with qualitative research. We explore this overlap and propose that technology design teams take up the challenge of innovation in technology by engaging in a participatory rather than clinician-driven process for future technology design. Implications for both research and clinical practice are explored.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This "perspective" paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations' access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the "solution to everything". In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial "Direct-To-Consumer" services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to "capabilities" supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing "public health value" through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Comfort With Telehealth Among Residents of an Underserved Urban Area

Background:

Deployment of telehealth has been touted as a means of reducing health disparities in underserved groups. However, efforts to reduce regulatory barriers have not been associated with greater telehealth uptake. The goal of this study was to examine engagement with technology among low-income people of color living in Newark, New Jersey.

Methods:

Using surveys and focus groups, we examined study participants’ daily use of technology (eg, Internet) and comfort with telehealth services (eg, use of teleconferencing for medication refills) before and after COVID-related social distancing mandates went into effect.

Results:

Use of technology was significantly lower in the pre-COVID period. However, prior months’ use of technology had a weak but significant correlation with comfort with telehealth (r = .243, P = .005) in bivariate analyses and was the only significant predictor in multivariate analyses. Analyses of focus group discussions confirmed that lack of experience with technology and distrust of the security and privacy of digital systems were the most important barriers to comfort with telehealth in our sample.

Conclusion:

Our study found that approximately 20% of people in this under-resourced community lacked access to basic technologies necessary for successful deployment of telehealth services. The study’s timing provided an unexpected opportunity to compare experiences and attitudes relating to telehealth in 2 regulatory environments. Although uptake of telehealth services increased with the Federal governments’ relaxation of regulatory barriers, there was not a similar increase in comfort with telehealth use. Investments in broadband access and equipment should be accompanied by educational programs to increase day-to-day use of and comfort with associated technologies which would improve consumer confidence in telehealth.

Public engagement in health technology assessment in Brazil: the case of the public consultation on National Clinical Guidelines for Care in Normal Birth

BACKGROUND

There is a growing body of literature that recognizes the importance of public engagement in health technology assessment. However, there is still uncertainty regarding how the results should be recorded, analyzed, and used by decision makers.

OBJECTIVE

Synthesize the contributions of the Brazilian public (women, health professionals, managers, educational institutions, and companies) about the implementation of the National Clinical Guidelines for Care in Normal Birth from the public consultation carried out in Brazil.

METHOD

IRaMuTeQ software was used to organize and summarize the corpus based on three types of analysis: descriptive statistics; descending hierarchical classification; and specificities analysis. The public consultation was conducted in 2016 by the National Committee for Health Technology Incorporation (CONITEC) in the Brazilian public health system as part of the guideline development process.

RESULTS

The corpus consisted of 303 texts, separated into 1233 text segments, 1081 of which were used, corresponding to retention of 87.67%. Five classes emerged from our analyses: mandatory presence of an obstetrician during labor and delivery in hospital settings; barriers and facilitators for guideline implementation; use of evidence-based practices by health professionals; progression of labor and delivery and women's rights; and mobilization to promote the guideline For each class, the most frequent words and sentences with the highest chi-squared scores were presented. Barriers were associated with lack of financial resources, training and professional motivation, and facilitators with training to change the practices of health professionals. Obstetric nurses emerged as an alternative for supervising normal births as well as the mandatory presence of an obstetrician during childbirth in hospital settings.

CONCLUSION

Our findings summarize the contributions provided by the Brazilian public and shed some light on the barriers and facilitators of clinical guidelines for care in normal birth. These topics are not typically explored by quantitative studies. Including this information in the decision-making process would not only increase public engagement, but provide greater evidence for implementing the clinical guidelines nationwide.

A “Not So Quiet” Revolution: Systemic Benefits and Challenges of Telehealth in the Context of COVID-19 in Quebec (Canada)

The COVID-19 pandemic has had a major impact on health and social service systems (HSSS) worldwide. It has put tremendous pressure on these systems, threatening access, continuity, and the quality of patient care and services. In Quebec (Canada), the delivery of care and services has radically changed in a short period of time. During the pandemic, telehealth has been widely deployed and used, notwithstanding the decades-long challenges of integrating this service modality into the Quebec HSSS. Adopting a narrative-integrative approach, this article describes and discusses Quebec's experience with the deployment and utilization of telehealth in the context of COVID-19. Firstly, we introduced the achievements and benefits made with the use of telehealth. Secondly, we discussed the challenges and concerns that were revealed or accentuated by the sanitary crisis, such as: (1) training and information; (2) professional and organizational issues; (3) quality of services and patient satisfaction; (4) cost, remuneration, and funding; (5) technology and infrastructure; (6) the emergence of private telehealth platforms in a public HSSS; (7) digital divide and equity; and (8) legal and regulatory issues. Finally, the article presents recommendations to guide future research, policies and actions for a successful integration of telehealth in the Quebec HSSS as well as in jurisdictions and countries facing comparable challenges.

Improving Health for People Living With Heart Failure: Focus Group Study of Preconditions for Co-Production of Health and Care

Background

Co-production of health and care involving patients, families of patients, and professionals in care processes can create joint learning about how to meet patients’ needs. Although barriers and facilitators to co-production have been examined previously in various health care contexts, the preconditions in Swedish chronic cardiac care contexts are yet to be explored. This study is set in the health system of the Swedish region of Jönköping County and is part of system-wide efforts to promote better health for persons with heart failure (HF).

Objective

The objective of this study was to test the usefulness of the Capability, Opportunity, and Motivation Behavior (COM-B) model when assessing the barriers to and facilitators of co-production of health and care perceived by patients with HF, family members of patients with HF, and professionals in a Swedish chronic cardiac care context as a guide for subsequent initiatives.

Methods

Data collection involved 1 focus group interview (FGI) with patients with HF (n=5), 1 FGI with family members of patients with HF (n=5), 1 FGI with professionals in primary care (n=7), and 1 FGI with professionals in cardiac care (n=4). In addition, patients with HF kept diaries of their thoughts regarding co-production. Using a deductive approach to content analysis, underpinned by the COM-B model, barriers and facilitators were categorized into capabilities, opportunities, and motivations to co-produce health and care.

Results

The participants showed limited understanding of co-production as a practice. They appeared to view it as a privilege to be offered to patients on top of traditional care and rarely as an approach for improving health care processes. The interviews revealed the limited health literacy among patients and the struggle of professionals to convey health information to these patients. Co-production was considered to be more resource-intensive than traditional care. Different expectations of stakeholders’ roles were revealed: professionals expected older patients not to want to co-produce health and care, and all participants expected professionals to be in charge of health care services. The family members’ position involved trying to balance their desire to support their relatives with understanding when, how, and with whom to co-produce. Presumed benefits motivated stakeholders: co-production was recognized to motivate patients to improve self-care. However, the participants recognized that motivation to get involved in health and care decisions varies over time among stakeholders.

Conclusions

Co-production can be facilitated by the stakeholders’ motivation. However, varying levels of understanding of co-production, patients’ limited health literacy, unease with power sharing between patients and professionals, and resource constraints are barriers that need to be managed to promote co-produced care and better health for persons living with HF. Further research is warranted to explore how to co-produce health care services with patients with HF and how leaders can facilitate the inevitable cultural change it requires and represents.

Why is repositioning public health innovation towards a social paradigm necessary? A reflection on the field of public health through the examples of Ebola and Covid-19

Health innovations are generally oriented on a techno-economic vision. In this perspective, technologies are seen as an end in themselves, and there is no arrangement between the technical and the social values of innovation. This vision prevails in sanitary crises, in which management is carried out based on the search for punctual, reactive, and technical solutions to remedy a specific problem without a systemic/holistic, sustainable, or proactive approach. This paper attempts to contribute to the literature on the epistemological orientation of innovations in the field of public health. Taking the Covid-19 and Ebola crises as examples, the primary objective is to show how innovation in health is oriented towards a techno-economic paradigm. Second, we propose a repositioning of public health innovation towards a social paradigm that will put more emphasis on the interaction between social and health dimensions in the perspective of social change. We will conclude by highlighting the roles that public health could play in allowing innovations to have more social value, especially during sanitary crises.

A multi-stakeholder approach to the co-production of the research agenda for medicines optimisation

BACKGROUND

Up to 50% of medicines are not used as intended, resulting in poor health and economic outcomes. Medicines optimisation is 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. The purpose of this exercise was to co-produce a prioritised research agenda for medicines optimisation using a multi-stakeholder (patient, researcher, public and health professionals) approach.

METHODS

A three-stage, multiple method process was used including: generation of preliminary research questions (Stage 1) using a modified Nominal Group Technique; electronic consultation and ranking with a wider multi-stakeholder group (Stage 2); a face-to-face, one-day consensus meeting involving representatives from all stakeholder groups (Stage 3).

RESULTS

In total, 92 research questions were identified during Stages 1 and 2 and ranked in order of priority during stage 3. Questions were categorised into four areas: 'Patient Concerns' [e.g. is there a shared decision (with patients) about using each medicine?], 'Polypharmacy' [e.g. how to design health services to cope with the challenge of multiple medicines use?], 'Non-Medical Prescribing' [e.g. how can the contribution of non-medical prescribers be optimised in primary care?], and 'Deprescribing' [e.g. what support is needed by prescribers to deprescribe?]. A significant number of the 92 questions were generated by Patient and Public Involvement representatives, which demonstrates the importance of including this stakeholder group when identifying research priorities.

CONCLUSIONS

A wide range of research questions was generated reflecting concerns which affect patients, practitioners, the health service, as well the ethical and philosophical aspects of the prescribing and deprescribing of medicines. These questions should be used to set future research agendas and funding commissions.

[Beyond benefit evaluation: Considering the unintended consequences of telehealth]

La télésanté est considérée comme un levier incontournable dans les choix des politiques en santé. Toutefois, il subsiste de nombreux enjeux face à son intégration réussie dans les pratiques cliniques. À ce jour, un grand nombre d’initiatives en télésanté peine à dépasser le stade de projet pilote. Cette situation s’explique en partie par une culture de l’innovation qui est principalement focalisée sur les bénéfices attendus de la technologie et moins sur les changements et les transformations qu’elle peut entraîner. La télésanté est utilisée dans des établissements de santé dont la dynamique sociale est pour le moins complexe. Son introduction entraîne des conséquences inattendues pouvant affecter aussi bien les patients, les communautés, les professionnels, les établissements que les systèmes de santé et la société dans son ensemble. L’objectif de cet article est de discuter de certaines des conséquences inattendues découlant de l’utilisation de la télésanté dans les établissements et systèmes de santé.

Citizen-Patient Involvement in the Development of mHealth Technology: Protocol for a Systematic Scoping Review

Background

The development of mobile technology for information retrieval and communication, both at individual and health organizational levels, has been extensive over the last decade. Mobile health (mHealth) technology is rapidly adapting to the health care service contexts to improve treatment, care, and effectiveness in health care services.

Objective

The overall aim of this scoping review is to explore the role of citizen-patient involvement in the development of mHealth technology in order to inform future interventions. By identifying key characteristics of citizen-patient involvement in system development, we aim to improve digital communication and collaboration between health care providers and citizen-patients, including sharing of health care data.

Methods

The systematic scoping review will follow the Joanna Briggs Institute methodology for scoping reviews by searching literature in 3 steps. We will include literature reporting on the public, citizens, and patients participating in the development of mobile technology for health care purposes in MEDLINE, CINAHL, Scopus, EMBASE, and ProQuest Dissertations and Theses. A preliminary search was completed in MEDLINE and Scopus. The screening process will be conducted by 2 of the authors. Data will be extracted using a data extraction tool prepared for the study.

Results

The study is expected to identify research gaps that will inform and motivate the development of mHealth technology. The final report is planned for submission to an indexed journal in November 2020.

Conclusions

To our knowledge, this review will be the first review to provide knowledge about how citizen-patients participate in system developments for mHealth tools and the value that such involvement adds to the system development process.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16781

[Organizational and systemic conditions of citizen-patient involvement in the development of telehealth in Quebec]

OBJECTIVES

Involving citizens-patients in decisions regarding telehealth services could allow a better match between the services offered and the needs and contexts of individuals and communities. This study aims to explore the organizational and systemic conditions that can influence citizen-patient involvement in the development of telehealth in Quebec.

METHODS

A qualitative study based on semi-structured interviews with 29 key informants was conducted. A deductive-inductive thematic analysis was performed based on an integrative framework derived from diffusion of innovation theories.

RESULTS

Citizen-patient involvement in the development of telehealth remains dependent on many organizational and systemic conditions. At the organizational level, it could affect the dynamics, process, cultures, rules and operations in organizations; hence the needs for adequate human and material resources as well as the availability of support for change. At the systemic level, the ideology, the sociopolitical context and the decisions in favor (or not) of a citizen appropriation of the decision-making are central. Concerns about scientific evidence, training, as well as the roles of professional federations, and citizen-patient groups have also emerged. Organizational and systemic levels are interdependent.

CONCLUSION

The organizational and systemic contexts may explain part of the contrast between the discourse in favor of citizen-patient involvement in telehealth decision-making and the reality observed in Quebec. This study provides a basis for analyzing citizen-patient involvement in services development from the perspective of organizational and systemic changes.