Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction

Media depictions of primary care teleconsultation safety: a thematic analysis of UK newspapers

BACKGROUND

The COVID-19 pandemic necessitated the widespread roll-out of teleconsultations across primary care services in the UK. The media's depiction of remote consultations, especially regarding their safety, is not well established. These insights are important: newspapers' coverage of healthcare-related news can influence public perception, national policy, and clinicians' job satisfaction.

AIM

To explore how the national newspapers in the UK depicted both the direct and indirect consequences of the remote-first approach on patient safety.

DESIGN AND SETTING

We performed thematic analysis of newspaper articles that discussed patient safety in primary care teleconsultations, which were published between 21 January 2021 and 22 April 2022.

METHOD

We identified relevant articles using the LexisNexis Academic UK database. We categorised data from these articles into codes before developing these into emergent themes through an iterative process.

RESULTS

Across the 57 articles identified, the main safety concern identified was missed and/or delayed diagnoses over tele-appointment(s), while isolated cases of inappropriate prescribing were also reported. The media reported that the transition to a remote-first approach reduced the accessibility to primary care appointments for some groups (especially patients with lower digital literacy or access) and heightened the burden on other healthcare services; in particular, there were reports of patient care being compromised across NHS emergency departments.

CONCLUSION

The print media predominantly reported negative impacts of remote consultations on patient safety, particularly involving missed and/ or delayed diagnoses. Our work highlights the importance of further exploration into the safety of remote consultations, and the impact of erroneous media reporting on policies and policymakers.

Challenges and recommendations in the implementation of audiovisual telemedicine communication: a systematic review

This systematic review aims to identify the elements of doctor-patient communication in telemedicine, emerging challenges, and proposed recommendations. Four databases, including Science Direct, PubMed, Cochrane, and ProQuest, were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria consisted of original research papers, availability of free full text, and publications during the past 10 years. A total of 13 articles completed the selection process and satisfied the established criteria. The issues and recommendations of telemedicine communication were categorized into three distinct groups: pre-consultation, during-consultation, and post-consultation. Preparation encompasses the arranging of visual elements, safeguarding patient privacy and confidentiality, and addressing any technical challenges that may arise. The consultation encompasses nonverbal behavior, empathy, the doctor-patient connection, and a physical examination. Post-telemedicine consultations refer to medical appointments that occur after a telemedicine session, typically involving follow-up medical interactions. Telemedicine presents unique challenges in doctor-patient consultations that differ from face-to-face interactions. Therefore, clinicians must acquire communication skills specific to telemedicine to ensure effective consultations and achieve optimal health results.

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis

BACKGROUND

Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.

SETTING AND SAMPLE

UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023.

METHODS

Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts.

RESULTS

Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions.

CONCLUSION

While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

Feasibility and acceptability of measuring positivity resonance in nurse-patient telehealth videoconferencing visits: A mixed-methods observational study

AIM

To investigate the feasibility and acceptability of the training process, procedures, measures and recruitment strategies necessary for a future investigation to test the reliability and validity of using positivity resonance measures in health care encounters.

BACKGROUND

Although the measurement of positivity resonance is promising, and non-participant observation is considered effective, their approaches to studying nurse-patient relationships have not been fully explored.

DESIGN

A mixed-methods observational study.

METHODS

Video recordings of 30 nurse-patient dyads completing telehealth video visit encounters were edited and coded using behavioural indicators of positivity resonance. A post-visit survey gathered data on the participants' perceptions of positivity resonance and the study procedures. The research team completed memos and procedural logs to provide narrative data on the study's training, coding, recruitment and operational procedures. The study included 33 persons with cancer and 13 oncology nurses engaging in telehealth video visit encounters at an academic oncology ambulatory care center located in the southeastern United States.

RESULTS

Study procedures were found to be feasible and acceptable to participants. An adequate sample of participants (N = 46) were enrolled and retained in the study. Interrater reliability, as evidenced by Cohen's weighted kappa, ranged from .575 to .752 and interclass correlation coefficients >.8 were attainable within a reasonable amount of time and with adequate training. Behavioural indicators of positivity resonance were observed in all telehealth visits and reported by the participants in the perceived positivity resonance survey. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist guided reporting.

CONCLUSIONS

Designing research around the concept of positivity resonance is an innovative and feasible approach to exploring how rapport is cultivated within nurse-patient relationships.

RELEVANCE TO PROFESSIONAL PRACTICE

Measuring positivity resonance may hold promise for exploring patient and nurse outcomes including trust, responsiveness, health-related behaviours, well-being, resilience and satisfaction.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist guided the reporting of results to ensure that adequate details of the study were provided to ensure an accurate and complete report.

PATIENT OR PUBLIC CONTRIBUTION

Planning of the research design and study procedures was done in consultation with nurse clinicians with experience with telehealth and managers responsible within the practice setting where the study was conducted. This ensured the study procedures were ethical, safe, secure and did not create unnecessary burden to the study participants. The study included collecting data from nurse and patient participants about the acceptability of the study procedures.

How Informal Carers Support Video Consulting in Physiotherapy, Heart Failure, and Cancer: Qualitative Study Using Linguistic Ethnography

BACKGROUND

Informal carers play an important role in the everyday care of patients and the delivery of health care services. They aid patients in transportation to and from appointments, and they provide assistance during the appointments (eg, answering questions on the patient's behalf). Video consultations are often seen as a way of providing patients with easier access to care. However, few studies have considered how this affects the role of informal carers and how they are needed to make video consultations safe and feasible.

OBJECTIVE

This study aims to identify how informal carers, usually friends or family who provide unpaid assistance, support patients and clinicians during video consultations.

METHODS

We conducted an in-depth analysis of the communication in a sample of video consultations drawn from 7 clinical settings across 4 National Health Service Trusts in the United Kingdom. The data set consisted of 52 video consultation recordings (of patients with diabetes, gestational diabetes, cancer, heart failure, orthopedic problems, long-term pain, and neuromuscular rehabilitation) and interviews with all participants involved in these consultations. Using Linguistic Ethnography, which embeds detailed analysis of verbal and nonverbal communication in the context of the interaction, we examined the interactional, technological, and clinical work carers did to facilitate video consultations and help patients and clinicians overcome challenges of the remote and video-mediated context.

RESULTS

Most patients (40/52, 77%) participated in the video consultation without support from an informal carer. Only 23% (12/52) of the consultations involved an informal carer. In addition to facilitating the clinical interaction (eg, answering questions on behalf of the patient), we identified 3 types of work that informal carers did: facilitating the use of technology; addressing problems when the patient could not hear or understand the clinician; and assisting with physical examinations, acting as the eyes, ears, and hands of the clinician. Carers often stayed in the background, monitoring the consultation to identify situations where they might be needed. In doing so, copresent carers reassured patients and helped them conduct the activities that make up a consultation. However, carers did not necessarily help patients solve all the challenges of a video consultation (eg, aiming the camera while laying hands on the patient during an examination). We compared cases where an informal carer was copresent with cases where the patient was alone, which showed that carers provided an important safety net, particularly for patients who were frail and experienced mobility difficulties.

CONCLUSIONS

Informal carers play a critical role in making video consultations safe and feasible, particularly for patients with limited technological experience or complex needs. Guidance and research on video consulting need to consider the availability and work done by informal carers and how they can be supported in providing patients access to digital health care services.

Comparisons of Communication in Medical Face-To-Face and Teleconsultations: A Systematic Review and Narrative Synthesis

The COVID-19 pandemic has brought telemedicine into mainstream medical practice (although questions remain over its role in a post-pandemic world). Research suggests that most patients and providers are satisfied with the flexibility and convenience of teleconsultations. However, there is continuing uncertainty about whether this shift has a clinically relevant impact on the quality of doctor-patient interaction. We conducted a systematic search of studies comparing communication in medical face-to-face consultations and teleconsultations. We included only studies which examined communication directly using recordings, excluding studies which used questionnaires or interviews. Studies were appraised using modified versions of the Critical Appraisal Skills Programme (CASP) checklists. Our search yielded 25,348 records, of which 22 were included in the final review. These studies were conducted in various medical specialties. Methodologies included approaches based on quantified communication behaviors using coding systems and qualitative studies using microanalytic methods. Except for duration (where there was evidence of face-to-face consultations being longer), no differences between the two modes of communication were consistently identified. In the aggregate, however, statistically significant differences were more prominent in primary care and more likely to favor face-to-face consultations. Qualitative studies also highlighted differences in how communication behaviors were manifested in each modality. Because much of the examined research was conducted in selected or non-routine settings, its applicability to the less selective use of telemedicine during and after the pandemic is limited.

Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders

BACKGROUND

High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it.

METHODS

This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers.

FINDINGS

Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety.

CONCLUSIONS

This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.

Communication in Telehealth: A State-of-the-Art Literature Review of Conversation-Analytic Research

We provide a state-of-the-art review of research on conversation analysis and telehealth. We conducted a systematic review of the literature, focusing on studies that investigate how technology is procedurally consequential for the interaction. We discerned three key topics: the interactional organization, the therapeutic relationship, and the clinical activities of the encounter. The literature on telehealth is highly heterogeneous, with significant differences between text-based care (e.g., via chat or e-mail) and audio(visual) care (e.g., via telephone or video). We discuss the extent to which remote care can be regarded as a demarcated field for study or whether the medium is merely part of the "context," particularly when investigating hybrid and polymedia forms of care involving multiple technological media.

A Systematic Review of Publications on Perceptions and Management of Chronic Medical Conditions Using Telemedicine Remote Consultations by Primary Healthcare Professionals April 2020 to December 2021 During the COVID-19 Pandemic

Telemedicine technologies allow distribution of health-related services and information and can include electronic and telecommunication technologies, remote patient and clinician contact, referral and prescribing, patient education, and monitoring. This systematic review aimed to evaluate publications on the perceptions and management of chronic medical conditions using telehealth remote consultations by primary healthcare professionals between April 2020 and December 2021 during the COVID-19 pandemic. Electronic databases, including Cinhal, PubMed, Science Direct, and ProQuest were searched to extract qualitative studies relevant to the topic. Inclusion criteria were developed based on the Population, Exposure, and Outcomes scoping framework. The target population was healthcare professionals working in primary care settings. Included studies encompassed various types of telemedicine, such as synchronous telemedicine, video conferencing, telephone conversations, and smart devices. Eight studies were included. Synchronous telemedicine was highly effective in ensuring the continuity of care and treatment, providing patients with convenience, improved access to treatment, and earlier disease management. Video conferencing and telephone consultations were the most common methods used. Challenges included concerns about patient privacy, technology literacy, and acceptance. Telemedicine was commended for its ability to provide access to immediate expert medical advice and eliminate the need for long-distance travel, contributing to increased patient compliance. Synchronous telemedicine is a promising solution for managing chronic conditions during and after the COVID-19 pandemic, offering benefits to patients and healthcare professionals. To maximize its potential, concerns regarding patient privacy, confidentiality, and technology literacy need to be addressed. Proper legislation and regulations are required for long-term success of telemedicine, making it a valuable component of healthcare systems.

Heart Failure Nurses within the Primary Care Setting

Cardiology services within primary care often focus on disease prevention, early identification of illness and prompt referral for diagnosis and specialist treatment. Due to advances in pharmaceuticals, implantable cardiac devices and surgical interventions, individuals with heart failure are living longer, which can place a significant strain on global healthcare resources. Heart failure nurses in a primary care setting offer a wealth of clinical knowledge and expertise across all phases of the heart failure trajectory and are able to support patients, family members and other community services, including general practitioners. This review examines the recently published evidence on the current and potential future practice of heart failure nurses within primary care.

Reaching for connection: a qualitative study of communication and interaction in video-based physiotherapy

OBJECTIVE

Digital technology has become increasingly relevant in physiotherapy, but little is known about communication and interaction in video-based physiotherapy. Therefore, this study aimed to explore the experiences among patients and physiotherapists, of communication and interaction in digital, video-based physiotherapy.

METHODS

A qualitative interview study with a phenomenological approach was conducted. Participants were purposively recruited from primary health care clinics. Semi-structured, in-depth interviews were conducted with 10 physiotherapists and 6 patients. Interviews were recorded, transcribed, and analyzed using a phenomenological approach.

RESULTS

The analysis resulted in the overall theme Reaching for connection, which captured the central meaning of the participants' experiences. Four categories emerged from the analysis: 1) Closeness at a distance; 2) Overcoming limited bodily communication; 3) The technology as part of the meeting; and 4) Challenging the physical meeting as a norm. The results suggest that communication and interaction in digital settings differ from physical settings, but there is an ongoing adaptation process to this new paradigm.

CONCLUSIONS

The results of this study show that video-based physiotherapy, while having several benefits according to both patients and physiotherapists, affects the communication in several ways. Physiotherapists need to acknowledge these limitations and seek strategies to adapt and to compensate for the reduced non-verbal elements and lack of touch. Attention to the physical room and shifting between positions (face/full figure) are suggested practical strategies, but also to practice awareness and embodied communication to improve receptivity in the interaction.

Telehealth and telemedicine prenatal care during the COVID-19 pandemic: a systematic review with a narrative synthesis

BACKGROUND

The COVID-19 epidemic has restricted the use of maternal health services, including prenatal care. Telehealth and telemedicine are remote services that can help in the event of a COVID-19 pandemic. In this study, we examined the use of telehealth and telemedicine in prenatal care in various countries during the COVID-19 pandemic.

METHODS

Relevant titles were searched in five e-book databases from 31 December 2019 to 31 July 2021: PUBMED, Science Direct, Scopus, Web of Sciences, and Google Scholar. Articles were chosen based on the following criteria: a focus on pregnant women, a connection to the COVID-19 pandemic, and a focus on telehealth and telemedicine. A narrative synthesis was used to synthesize the data.

RESULTS

Telehealth and telemedicine reduced the risk of transmitting COVID-19 to pregnant women and health workers. The implementation process encountered various challenges, such as the absence of service composition, limited technological accessibility, communication difficulties, and disparities in access.

CONCLUSIONS

It is imperative for the government and health organizations to have a comprehensive policy and legislation that effectively regulates the provision of services. It is also important to emphasize the importance of reducing inequality, such as by equalizing access to technology and infrastructure.

Patients preferences for communication during video consultations

Objective The aim of our simulation-based study was to explore patient preferences for physician behaviours in video consultations METHODS: We conducted an exploratory study in outpatient setting in Geneva, Switzerland.Patients were invited to watch two variations videos of six simulated physician communication behaviours (camera framing, gaze orientation, initial talk at the opening phase, privacy reminder, pauses, empathy)and to indicate which one they preferred RESULTS: 417 patients watched three different video-recorded encounters. Most patients preferred framing with both face and bust (50.7 %) versus face alone (21.8 %). They valued eye gazing towards the camera (42.9 %) versus eye gazing shifting between screen and camera (13 %). The social talk related to the connection quality was appreciated (43.1 % vs 17.1 %) as well as the privacy reminder (80.8 % vs 6.5 %). Patients preferred short rather than long pauses after physician's statements (63.9 vs 14.9 %) as well as expressive rather than neutral nonverbal behaviour (46.7 % vs 17.6 %). CONCLUSION: Our results confirm that patients prefer the use of video specific communication behaviours recommended by experts except for shifting eye gaze and long pauses after physician's statements. PRACTICE IMPLICATIONS: Given the increasing use of video consultations, video communication "best practices"should be systematically addressed in physician training.

Experiences of South African speech-language therapists providing telepractice during the COVID-19 pandemic: A qualitative survey

BACKGROUND

The COVID-19 pandemic necessitated that speech-language therapists (SLTs) make a radical change to provide services to their clients safely via telepractice. For many practitioners, telepractice was an unfamiliar mode of practice that had to be implemented under emergency conditions. Limited literature on SLTs' experiences of implementing telepractice in the Global South during this time is available.

AIMS

To explore the experiences of South African SLTs (N = 45) who implemented telepractice services during the COVID-19 pandemic.

METHODS & PROCEDURES

SLTs across the country were invited via professional bodies to participate in an online qualitative survey distributed in 2021. Data were analysed using thematic analysis principles.

OUTCOMES & RESULTS

We describe participants' reports of their current telepractices, discuss their perspectives on accessibility to telepractice for SLTs, clients and caregivers, and working with specific diagnoses, and consider the support needs of SLTs to enhance telepractice services. Most participants work in private practice or school settings with primarily paediatric caseloads. They reported telepractice as a positive experience and felt it was effective, although they judged that some clients were not well served by telepractice. SLTs felt underprepared for the rapid switch to telepractice and the flexibility required, especially given the limited availability of guidelines given the pandemic crisis. Greater preparation is required for telepractice sessions and more attention needs to be paid to supporting caregiver involvement online.

CONCLUSIONS & IMPLICATIONS

Telepractice involves various barriers and facilitators, many of which seem common across Global North and South contexts. Support is required to enhance current telepractices in terms of computer literacy, technical education, different telepractice methods and caregiver coaching. Our findings have the potential to enable the development of support, training and guidelines to improve SLTs' confidence in providing telepractice whilst delivering quality services in an accessible and safe manner.

WHAT THIS PAPER ADDS

What is already known on the subject Many SLTs had to transition quickly to telepractice service provision during COVID-19, with limited existing guidelines and support. Although there is some literature available on SLTs' experiences of implementing telepractice in the Global North, perspectives from the Global South during this time are limited. It is important to understand experiences, barriers and facilitators to telepractice provision to provide tailored support to practitioners. What this paper adds to existing knowledge Telepractice provides a viable alternative to in-person therapy for specific clients and contexts. Telepractice presents both benefits and barriers for effective clinical practice across Global North and South contexts. Greater preparation is required for telepractice sessions and more attention needs to be paid to enhancing caregiver involvement online, especially since many practitioners are likely to continue offering telepractice services post-pandemic. What are the potential or actual clinical implications of this work? Clinicians felt underprepared for the rapid switch from service delivery mode to telepractice. Greater support, training and guidelines for students and practitioners are required to enhance current practices and ensure practitioners are equipped to provide effective telepractice in the future. In particular, support should cover technological aspects, caregiver coaching and online assessment options, especially for paediatric clients.

Pedi-R-MAPP | the development, testing, validation, and refinement of a digital nutrition awareness tool

BACKGROUND & AIMS

The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments and provide practical guidance for nutritional care. R-MAPP was adapted into Pediatric Remote Malnutrition Application (Pedi-R-MAPP) using a modified Delphi consensus, with the goal of providing a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. The aim of this study was to develop and validate a digital version of Pedi-R-MAPP using the IDEAS framework (Integrate, Design, Assess and Share).

METHODS

A ten-step process was completed using the IDEAS framework. This involved the four concept processes; Stage-1, Integrate (Step 1-3) identify the problem, specify the goal, and use an evidence-based approach. Stage-2, (Step 4-7) design iteratively and rapidly with user feedback. Stage 3, (Step 8-9) Assess rigorously, and Stage 4 (Step 9-10) publish and launch of the tool.

RESULTS

Stage 1:Evidence-based development, Pedi-R-MAPP was developed using Delphi consensus methodology. Stage 2:Iteration & design, HCPs (n = 22) from UK, Europe, South Africa, and North America were involved four workshops to further develop a paper prototype of the tool and complete small-scale testing of a beta version of the tool which resulted in eight iterations. Stage 3:Assess rigorously, Small scale retrospective testing of the tool on children with congenital heart disease (n = 80) was completed by a single researcher, with iterative changes made to improve agreement with summary advice. Large scale testing amongst (n = 745) children in different settings was completed by specialist paediatric dietitians (n = 15) advice who recorded agreement with the summary advice compared with their own clinical assessment. Paediatric dietitians were in overall agreement with the summary advice in the tool 86% (n = 640), compared to their own clinical practice. The main reasons for disagreement were i) frequency of planned review 57.1% (n = 60/105), ii) need for ongoing dietetic review due to chronic condition 20.0% (n = 21/105), iii) disagreement with recommendation for discharge 16.2% (n = 17/105) and iv) concerns with faltering growth and/or need for condition specific growth charts 6.7% (7/105). Iterative changes were made to the algorithm, leading to an improvement in agreement of the summary advice on re-evaluation to 98% (p=<0.0001).

CONCLUSION

A digital version of the Pedi-R-MAPP nutrition awareness tool was developed using the IDEAS framework. The summary advice provided by the tool achieved a high level of agreement when compared to paediatric dietetic assessment, by providing a structured approach to completing a remote nutrition focused assessment, along with identifying the frequency of follow-up or an in-person assessment.

Rapid implementation of remote digital primary care in Stockholm and implications for further system-wide implementation: practitioner's and manager's experience of the Always Open mobile application

OBJECTIVE

To contribute actionable knowledge how to increase appropriate use of digital technologies in primary care by understanding clinical managers experiences with a digital connection system, Always Open, during the COVID-19 pandemic.

DESIGN AND SUBJECTS

The overall design was a qualitative study with directed content analysis method. Data were collected from documents and focus group (n = 12) interviews with clinical managers (n = 99) of primary care. The seven domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework was used to understand the implementation process, as described by the clinical managers.

RESULTS

Focus group participants reported that their units made their own local decisions to make more use of the technology provided by the health system. Most participants considered that the technology was ready to use, despite some limitations, that included individual clinician's and patient preferences, and how ready their unit was for making changes to practice and organization. Some raised concerns about how standardizing some aspects possibly conflicted with the decentralized management model of the organization. The overall experience was reported to be positive, with an intention to sustain the achievements.

CONCLUSION

Focus group interviews found that clinical unit managers reported that they and their staff were positive about the digital technology system for remote care. For the future, they wanted changes to be made at different levels of the health system to better combine digital and physical care. Possibilities to use digital technology to integrate primary and hospital health care were identified.

Benefits and challenges of telemedicine for heart failure consultations: a qualitative study

BACKGROUND

Prior to the Covid-19 pandemic, heart failure (HF) disease management programmes were predominantly delivered in-person, with telemedicine being uncommon. Covid-19 resulted in a rapid shift to "remote-by-default" clinic appointments in many organisations. We evaluated clinician and patient experiences of teleconsultations for HF.

METHODS

From 16th March 2020, all HF appointments at a specialist centre in the UK were telemedicine-by-default through a mixture of telephone and video consultations, with rare in-person appointments. HF clinicians and patients with HF were invited to participate in semi-structured interviews about their experiences. A purposive sampling technique was used. Interviews were conducted using Microsoft Teams®, recorded and transcribed verbatim. Narrative data were explored by thematic analysis. Clinicians and patients were interviewed until themes saturated.

RESULTS

Eight clinicians and eight patients with HF were interviewed before themes saturated. Five overarching themes emerged: 1) Time utilisation - telemedicine consultations saved patients time travelling to and waiting for appointments. Clinicians perceived them to be more efficient, but more administrative time was involved. 2) Clinical assessment - without physical examination, clinicians relied more on history, observations and test results; video calls were perceived as superior to telephone calls for remote assessment. Patients confident in self-monitoring tended to be more comfortable with telemedicine. 3) Communication and rapport - clinicians experienced difficulty establishing rapport with new patients by telephone, though video was better. Patients generally did not perceive that remote consultation affected their rapport with clinicians. 4) Technology - connection issues occasionally disrupted video consultations, but overall patients and clinicians found the technology easy to use. 5) Choice and flexibility - both patients and clinicians believed that the choice of modality should be situation-dependent.

CONCLUSIONS

Telemedicine HF consultations were more convenient for patients, saved them time, and were generally acceptable to clinicians, but changed workflows, consultation dynamics, and how clinical assessment was performed. Telemedicine should be used alongside in-person appointments in a "hybrid" model tailored to individual patients and settings.

The impact of COVID-19 national restrictions on dental antibiotic dispensing trends and treatment activity in England: January 2016 to July 2021

Introduction

Reducing inappropriate antibiotic prescribing tempers the growing threat of antimicrobial resistance. We aimed to quantify the associated impact of COVID-19-related national restrictions in England on dental antibiotic dispensing and describe changes in appointments and modes of delivery of care.

Methods

Interrupted time series analyses were completed using NHS Business Service Authority (NHSBSA) ePACT2 data to measure the associated change in antibiotic dispensing in England following COVID-19-related restrictions (which began March 2020). For face-to-face dental consultations, NHS dental treatment plan (FP17) data were used. For remote consultations during the COVID-19 period, NHSBSA Compass system remote management data were used.

Results

Between January 2016 and February 2020, there was a decreasing trend in antibiotic dispensing (-0.02 per 1000 population per month, P < 0.05). In contrast, there was an increase of 0.98 per 1000 population (P < 0.05) in March. The peak in antibiotic use occurred between June 2020 and July 2020, once the restrictions were eased. At the end of the study period (July 2021), the elevated prescribing trend had not returned to pre-pandemic counterfactual levels, although exhibiting a declining trend. A stable trend in dental treatment plans was seen pre-COVID-19, with a sharp decline coinciding with the restrictions. Dental treatment plans had not yet returned to the higher pre-pandemic levels.

Conclusions

Dental antibiotic prescribing significantly increased with the national COVID-19 restrictions when service delivery was altered with the closure of dental practices and introduction of remote consultations. Teledentistry was likely associated with inappropriate antibiotic prescribing. Continued antimicrobial stewardship and prudent use of antibiotics in dentistry is important.

Health Communication Research Informs Inflammatory Bowel Disease Practice and Research: A Narrative Review

Background

In the absence of targeted empirical evidence on effective clinical communication in inflammatory bowel disease (IBD), a broad overview of existing evidence on effective communication in healthcare and available recommendations for communication in telehealth is provided and mapped onto IBD research and practice.

Methods

A narrative literature review was conducted using Pubmed and Scopus databases and snowballing literature search.

Results

Evidence-based relationship building strategies include communicating emotions, acknowledging and addressing patients' hesitancy, and ensuring continued support. A particular recommendation regarding telehealth interaction is to avoid long stretches of talk. Effective informational strategies include facilitating and supporting information exchange and considering patients' preferences in decision-making. In teleconsultations, clinicians should ask direct questions about patients' emotional state, clarify their understanding of patients' concerns and check patients' understanding, address at least one patient-reported outcome when discussing the recommended treatment, and shorten the consultation where possible. Strategies for maximizing effective clinical communication in the spoken communicative mode include using infographics and simple language, and assessing adherence at the beginning of the consultation. For teleconsultations, clinicians are advised to allow patients to explain the reason for their call at the beginning of the teleconsultation, probe additional concerns early and before ending the teleconsultation, and be mindful of technical issues such as voice delays.

Conclusions

Use of question prompt lists, decision aids, micro-lessons, and communication training interventions for clinicians could be beneficial in IBD care. Further research into the implementation of such interventions as well as clinical communication concerns specific to IBD is warranted.

Patient characteristics associated with the acceptability of teleconsultation: a retrospective study of osteoporotic patients post-COVID-19

BACKGROUND

Due to the COVID-19 pandemic, teleconsultations (TCs) have become common practice for many chronic conditions, including osteoporosis. While satisfaction with TCs among patients increases in times of emergency, we have little knowledge of whether the acceptability of TCs persists once in-person visits return to being a feasible and safe option. In this study, we assess the acceptability of TCs across five dimensions for osteoporosis care among patients who started or continued with TCs after the COVID-19 pandemic had waned. We then explore the patient characteristics associated with these perceptions.

METHODS

Between January and April 2022, 80 osteoporotic patients treated at the Humanitas Hospital in Milan, Italy, were recruited to answer an online questionnaire about the acceptability of TCs for their care. The acceptability of TCs was measured using a modified version of the Service User Technology Acceptability Questionnaire (SUTAQ), which identifies five domains of acceptability: perceived benefits, satisfaction, substitution, privacy and discomfort, and care personnel concerns. Multivariable ordinary least squares (OLS) linear regression analysis was performed to assess which patient characteristics in terms of demographics, socio-economic conditions, digital skills, social support, clinical characteristics and pattern of TC use were correlated with the five domains of acceptability measured through the SUTAQ.

RESULTS

The degree of acceptability of TCs was overall good across the 80 respondents and the five domains. Some heterogeneity in perceptions emerged with respect to TCs substituting for in-person visits, negatively impacting continuity of care and reducing the length of consultations. For the most part, acceptability was not affected by patient characteristics with a few exceptions related to treatment time and familiarity with the TC service modality (i.e., length of osteoporosis treatment and number of TCs experienced by the patient).

CONCLUSIONS

TCs appear to be an acceptable option for osteoporosis care in the aftermath of the COVID-19 pandemic. This study suggests that other characteristics besides age, digital skills and social support, which are traditionally relevant to TC acceptability, should be taken into account in order to better target this care delivery modality.

Satisfaction with Telepsychiatry during the COVID-19 pandemic: Patients' and psychiatrists' report from a University Hospital

BACKGROUND

The COVID-19 pandemic has led to important changes in the approach to patients worldwide. Different agencies have proposed and implemented telemedicine-based care services in order to ensure access to health care for all people.

AIM

The aim of this study was to determine the satisfaction of patients using the Telepsychiatry service offered by the Department of Psychiatry of the Hospital de Clínicas (National University of Asunción, Paraguay).

METHODS

A cross sectional and descriptive study has been conducted. Participants were recruited through a phone-based survey. Satisfaction with Telepsychiatry has been measured with an adapted version of a satisfaction survey in Teleneurology. As a complement, psychiatrists from the Hospital de Clínicas were also interviewed about their rate of satisfaction with Telepsychiatry.

RESULTS

A total of 530 patients were included, 51.3% of whom were women. The consultation satisfaction scale ranged between 2.15 and 4.30 with a mean score of 3.02 ± 0.32. Cronbach's alpha for the scale was .897, indicating a good internal consistency. Patients' satisfaction was higher for the perception of Telepsychiatry and lower for the doctor-patient relationship. Of the physicians, 87.5% were satisfied with the Telepsychiatry service.

CONCLUSION

The satisfaction overall score indicates patients' general satisfaction with the quality of care in Telepsychiatry, mainly regarding the perception of health care. and lower satisfaction with the doctor-patient relationship. Nine out of 10 psychiatrists felt satisfied with the Telepsychiatry service and considered that the degree of patient's satisfaction was acceptable during the Telepsychiatry consultation.

Preferences for support in managing symptoms of an asthma flare-up: a pilot study of a discrete choice experiment

Objective: Information on the preferences of people with asthma for support in managing a flare-up can inform service design which may facilitate appropriate help-seeking. To date, little is known about support preferences for managing a flare-up. The aim of this study was to develop and pilot a discrete choice experiment (DCE) to elicit the preferences of people with asthma with regards to support in managing a flare-up.Methods: Steps in developing the DCE included identification and selection of attributes and levels of the support services, construction of choice tasks, experimental design, construction of DCE instrument, and pretest (n=16) and pilot (n=38) studies of the DCE instrument. A multinomial logit model was used to examine the strength and direction of the six attributes in the pilot study.Results: Our results indicate that from a patient perspective, having a healthcare professional that listens to their concerns was the most valued attribute of support in asthma flare-up management. The other features of support valued by participants were timely access to consultation, a healthcare professional with knowledge of their patient history, a specialist doctor and face-to-face communication. Having a written action plan was the least valued attribute.Conclusions: Our findings suggest patient preference for a model of support in managing their symptoms which includes timely, face-to-face access to a healthcare professional that knows them and listens to their concerns. The findings of the pilot study need to be verified with a larger sample and using models to account for preference heterogeneity.

Adoption of video consultations during the COVID-19 pandemic

BACKGROUND

Video consultations have the potential to play a significant role for the future of healthcare by solving some of the imminently arising healthcare challenges, as pointed by the European Commission in Europe and the National Academy of Medicine in the United States of America. This technology can improve quality, efficiency, and enhance access to healthcare.

OBJECTIVE

The aim of this study is to explore and understand individual video consultations acceptance drivers.

METHODS

An extended technology acceptance model was created based on the diffusion of innovation theory (DOI), unified theory of acceptance and use of technology (UTAUT), health belief model (HBM), and concerns for information privacy framework (CFIP). 346 valid responses were collected through an online questionnaire, and the partial least squares (PLS) modeling approach was used to test the model.

RESULTS

The model explained 77.6 % (R2) of the variance on intention to use, and 71.4 % (R2) of the variance in attitude. The predictors of intention to use are attitude (beta = 0.504, p-value<0.001), performance expectancy (beta = 0.196, p-value = 0.002), and COVID-19 (beta = 0.151, p-value<0.001). The predictors of attitude are performance expectancy (beta = 0.643, p-value>0.001), effort expectancy (beta = 0.138, p-value = 0.001), and COVID-19 (beta = 0.170, p-value<0.001).

CONCLUSIONS

This research model highlights the importance of creating extended acceptance models to capture the specificities of each technology in healthcare. The model created helps to understand the most important drivers of video consultation acceptance, highlighting the importance of the COVID-19 pandemic and perceived health risks.

Towards multimodal boosting of motivation for fall-preventive physical activity in seniors: An iterative development evaluation study

Background

Many seniors need to increase their physical activity (PA) and participation in fall prevention exercise. Therefore, digital systems have been developed to support fall-preventive PA. Most of them lack video coaching and PA monitoring, two functionalities that may be relevant for increasing PA.

Objective

To develop a prototype of a system to support seniors' fall-preventive PA, which includes also video coaching and PA monitoring, and to evaluate its feasibility and user experience.

Methods

A system prototype was conceived by integrating applications for step-monitoring, behavioural change support, personal calendar, video-coaching and a cloud service for data management and co-ordination. Its feasibility and user experience were evaluated in three consecutive test periods combined with technical development. In total, 11 seniors tested the system at home for four weeks with video coaching from health care professionals.

Results

Initially, the system's feasibility was non-satisfactory due to insufficient stability and usability. However, most problems could be addressed and amended. In the third (last) test period, both seniors and coaches experienced the system prototype to be fun, flexible and awareness-raising. Interestingly, the video coaching which made the system unique compared to similar systems was highly appreciated. Nonetheless, even the users in the last test period highlighted issues due to insufficient usability, stability and flexibility. Further improvements in these areas are needed.

Conclusions

Video coaching in fall-preventive PA can be valuable for both seniors and health care professionals. High reliability, usability and flexibility of systems supporting seniors are essential.

Exploring patient participation during video consultations: A qualitative study

Objective

Video consultations enable a digital point of contact between the general practitioner and patient. With their medium-specific characteristics, video consultations may create novel conditions for the enactment of patient participation during consultations. Although numerous studies have explored patients' experiences of video consultations, research explicitly investigating patient participation within this new consultation setting remains sparse. This qualitative study explores how patients participate during interactions with their general practitioner by drawing on the affordances of video consultations.

Methods

The data corpus comprises eight recorded video consultations (59 minutes and 19 seconds in total) between patients and their general practitioner, all subjected to reflexive thematic analysis yielding three themes illustrating concrete participatory use cases.

Results

We find that video consultations provide an accessible format for patients otherwise unable to attend a physical consultation due to physical and mental barriers. Moreover, patients participate by drawing on resources situated in their spatial setting to settle health-related questions of doubt arising during the consultation. Lastly, we posit that patients enact participation by visually communicating their impromptu engagement in decision-making and reporting to their general practitioner by making use of the qualities of their smartphone during their consultation.

Conclusions

Our findings illustrate how video consultations provide a communicative context in which patients may enact distinct forms of participation by drawing on its technologically contingent affordances during interactions with their general practitioner. More research is needed to explore the participatory opportunities of video consultations in telemedical healthcare services for different patient groups.

The patient acceptability of a remotely delivered pain management programme for people with persistent musculoskeletal pain: A qualitative evaluation

Introduction

Remotely delivered pain management programmes have been offered in place of in-person programmes by many chronic pain services since the onset of the COVID-19 pandemic. There is a lack of evidence regarding the acceptability of these programmes. In this evaluation, we have explored patients' acceptability of a remotely delivered pain management programme for patients with persistent musculoskeletal pain.

Methods

Qualitative data were collected using focus groups with participants who had previously attended the remote pain management programme. Data were analysed using abductive analysis.

Results

Three focus groups were conducted with a total of 13 participants. The programmme was either entirely acceptable, had some acceptable components or was not acceptable to patients. Factors leading to the programme being acceptable include learning to manage pain from home, receiving high quality care from home, enhancing the potential of rehabilitation using technology, enabling attendance on a pain management programme from home, overcoming social distancing requirements of COVID-19 using technology, and virtual peer support. Factors leading to the programme not being acceptable include having an inappropriate home environment for virtual therapy, communication challenges with virtual therapy, technological issues and concerns regarding the quality of care.

Conclusions

There is a spectrum of acceptability with respect to the remote programme. The factors that influence this are dynamic, individual and situational. Hybrid programmes have the potential to enhance access to pain management programmes and improve patient experience and programme outcomes in the future.

Patient Care via Video Consultations: Piloting and S.W.O.T. Analysis of a Family Medicine Digitally Synchronous Seminar for Medical Students

Background: There is a need to familiarize medical students with the specifics of video consultations. This paper presents the concept and tests of a digitally synchronous distance seminar in which medical students practice video consultations as an aid to a family physician’s activity in a patient-oriented manner. The aim of the evaluation was to analyze the strengths, weaknesses, opportunities, and threats (S.W.O.T.) of the teaching concept. Methods: A total of 12 students carried out video consultations independently and under medical supervision. The seminar included two elements: (A) All students and teachers were video consulted in a family practice; (B) A small group performed a video consultation in a patient´s home environment. The students’ evaluation was conducted with two questionnaires (pre/post), which were analyzed with descriptive statistics and qualitative content analysis. The S.W.O.T. analysis was elaborated by the author team based on the results of the questionnaires and the interviews with the teachers. Results: Students learned the limits and possibilities of teleconsultations and deepened their family medical knowledge. Strengths: Among others; increase interest in video consultations, patient contact, focused work. Weaknesses: Among others; technical difficulties and the time it requires. Opportunities: Among others; involve students with multiple workloads in patient teaching. Risks: Among others; no integration into the curriculum yet, few personnel resources. Conclusions: The learning model familiarizes medical students with competences in family medical patient care using video communication. The results of S.W.O.T. analyses can be weighted differently. Project groups can decide individually if they want to integrate the learning concept into their curriculum and which further improvements are necessary.

Agency and the telephone: Patient contributions to the clinical and interactional agendas in telehealth consultations

OBJECTIVE

Patient-centredness is central to providing safe care and is achieved, in part, through involving patients in developing the agenda of the consultation. Medical consultations have changed significantly over the last two years as a result of COVID-19 and thus understanding how patients contribute to the clinical and interactional agendas within a telehealth consultation is important to supporting quality care.

METHODS

A collection (15) of consultations (in English) between specialists (3) and patients (14) were recorded in a metropolitan gastrointestinal clinic in Australia. These recordings were closely examined using conversation analysis, which focuses on the structural and sequential organisation of interaction.

RESULTS

Patients used a variety of interactional approaches to contribute to the agenda throughout the consultations. This was achieved in collaboration with the doctors, whose responses generally allowed for these contributions. However, there were few doctor-driven, explicit opportunities provided to patients to contribute to the agenda.

CONCLUSION

Many patients and doctors are adept at managing the interactional challenges of telehealth consultations but there are clear opportunities to extend this advantage to those patients with less agency.

PRACTICE IMPLICATIONS

Providing an explicit space for patients to ask questions within the consultation would support those patients less inclined or able to assert themselves during a telehealth consultation.

Exploring Nurse and Patient Experiences of Developing Rapport During Oncology Ambulatory Care Videoconferencing Visits: A Qualitative Study (Preprint)

Background

Although videoconferencing between oncology patients and nurses became routine during the pandemic, little is known about the development of clinician-patient rapport in this care environment. Evidence that virtual visits may challenge nurses’ ability to form connections with patients, demonstrate empathy, and provide support suggests that videoconferencing may not ensure optimal care for persons with cancer. Establishing rapport during videoconferencing visits (VCVs) is important in oncology nursing, as rapport enables the nurse to provide emotional support and assistance to patients as they navigate their cancer journey.

Objective

This study investigated the nature of nurse-patient rapport in ambulatory cancer care videoconferencing telehealth visits. Objectives included exploring (1) how patients with cancer and nurses describe experiences of and strategies for cultivating rapport and (2) similarities and differences between rapport in videoconferencing and in-person visits (IPVs).

Methods

In this qualitative descriptive study, interviews were conducted from October 2021 to March 2022 with 22 participants, including patients with cancer (n=10, 45%) and oncology nurses (n=12, 55%), about their experiences of rapport building during VCVs. All interviews were analyzed using conventional content analysis. Data from nurses and patients were analyzed separately using identical procedures, with a comparative analysis of patient and nurse results performed in the final analysis.

Results

Most patients in the study had experienced 3-5 video visits within the past 12 months (n=7, 70%). Half of the nurse participants (n=6, 50%) reported having participated in over 100 VCVs, and all had experiences with videoconferencing (ranging from 3 to 960 visits) over the past 12 months. In total, 3 themes and 6 categories were derived from the patient data, and 4 themes and 13 categories were derived from the nurse data. Comparisons of themes derived from participant interviews identified similarities in how nurses and patients described experiences of rapport during VCVs. Three themes fit the collective data: (1) person-centered and relationship-based care is valued and foundational to nurse-patient rapport in oncology ambulatory care regardless of how care is delivered, (2) adapting a bedside manner to facilitate rapport during VCVs is feasible, and (3) nurses and patients can work together to create person-centered options across the care trajectory to ensure quality care outcomes. Barriers to relationship building in VCVs included unexpected interruptions from others, breaks in the internet connection, concerns about privacy, and limitations associated with not being physically present.

Conclusions

Person-centered and relationship-based approaches can be adapted to support nurse-patient rapport in VCVs, including forming a personal connection with the patient and using active listening techniques. Balancing the challenges and limitations with the benefits of videoconferencing is an essential competency requiring additional research and guidelines.

International Registered Report Identifier (IRRID)

RR2-10.2196/27940

Using Linguistic Ethnography to Study Video Consultations: A Call to Action and Future Research Agenda

Video consultations are a rapidly growing service model, particularly in secondary care. Studies, mainly using trials and post-hoc surveys, have routinely documented that they can be a safe and effective means to deliver care at a distance. While video offers new opportunities to provide health services, it also constrains how patients and clinicians can interact, raising questions about feasibility, quality, and safety-questions that cannot be adequately addressed with prevailing methods and approaches. To support successful and appropriate implementation, use and spread of video consultations, we need to investigate how video changes the interaction. In this article, we use two worked examples to demonstrate how Linguistic Ethnography, a methodological approach combining ethnographic with linguistic analysis, enables a detailed understanding of how communication in video consultations works, providing an evidence base to support patients and clinicians with using this service model.

Patients' and clinicians' experiences of remote consultation? A narrative synthesis

Aims

To identify, evaluate and summarize evidence of patient and clinician experiences of being involved in video or telephone consultations as a replacement for in‐person consultations.

Design

Narrative synthesis.

Data sources

Medline; EMBASE; EMCARE; CINAHL and BNI. Searching took place from January 2021 to April 2021. Papers included were published between 2013 and 2020.

Review Methods

Papers were appraised by two independent reviewers for methodological quality. Data extraction was conducted according to the standardized tool from Joanna Briggs Institute.

Results

Seven qualitative studies were included, from five countries and from the perspective of patients, relatives, administrators, nurses, physiotherapists and physicians. We developed two main themes: Pragmatic Concerns and Therapeutic Concerns. Each theme contained two categories: Pragmatic Concerns: (a) the convenience of non‐face to face consultations; (b) using technology and equipment in a consultation; Therapeutic Concerns (c) building therapeutic relationships; and (d) embracing benefits and addressing challenges.

Conclusion

This narrative synthesis presents the existing evidence on clinician and patient experience of participating in non‐face to face consultations. Experiences are varied but largely focus on communication and forming relationships, using the technology successfully and the ability for patients to self‐manage with support from clinicians who are not in‐person. More high‐quality studies are required to explore the experiences of patients and clinicians accessing remote consultations as a result of global implementation post‐SARS‐CoV‐2 pandemic to identify any learning and education opportunities.

Impact

Health care staff can provide high‐quality care through video or telephone appointments as well as face to face appointments. This review has, however, identified that the evidence is limited and weak in this area and recommends there is research further to inform practice and influence future care.

Digital Health Paradox: International Policy Perspectives to Address Increased Health Inequalities for People Living With Disabilities

The COVID-19 pandemic accelerated the uptake of digital health worldwide and highlighted many benefits of these innovations. However, it also stressed the magnitude of inequalities regarding accessing digital health. Using a scoping review, this article explores the potential benefits of digital technologies for the global population, with particular reference to people living with disabilities, using the autism community as a case study. We ultimately explore policies in Sweden, Australia, Canada, Estonia, the United Kingdom, and the United States to learn how policies can lay an inclusive foundation for digital health systems. We conclude that digital health ecosystems should be designed with health equity at the forefront to avoid deepening existing health inequalities. We call for a more sophisticated understanding of digital health literacy to better assess the readiness to adopt digital health innovations. Finally, people living with disabilities should be positioned at the center of digital health policy and innovations to ensure they are not left behind.

Telepsychiatry: learning from the pandemic

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

Experiencing the SARS-CoV-2 Pandemic Whilst Living With Cancer

The SARS-CoV-2 pandemic has resulted in considerable consequences for many cancer patients, exacerbating pre-existing systemic health system limitations as well as creating new challenges. From socially distanced clinics and the widespread introduction of telehealth, to the halting of clinical trials and the reassessment of what constitutes "essential" treatment, care in oncology has abruptly changed. There is currently limited analysis of cancer patients' experiences of the pandemic and its impacts on illness, wellness, and everyday life. Through semi-structured interviews with 54 people living with cancer during the 2020 phase of the SARS-CoV-2 pandemic in Australia, we explore how patients experience illness and care in reflecting upon a range of pandemic challenges, including delay, distance, and vulnerability. We find that in some cases, these pandemic conditions redefined the meaning of essential cancer care, reconfigured expectations around clinical trials, constructed new affective distances, and amplified dread and fear for people living with cancer.

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

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

Challenges faced by doctors and nurses in wound care management during the COVID-19 pandemic in Turkey and their views on telehealth

AIM

This study aimed to determine the problems faced by physicians and nurses dealing with chronic wound care during the COVID-19 pandemic and their views on telehealth.

MATERIALS AND METHODS

A descriptive and cross-sectional design was used in this study. The sample comprised physicians (n = 74) and nurses (n = 271) interested in chronic wound care. Data were collected through a questionnaire form consisting of open- and closed-ended questions.

RESULTS

Of the participants, 21.4% (n = 74) were physicians and 78.6% (n = 271) were nurses. Of the physicians, 45.9% (n = 34) were obliged to work in another unit during the COVID-19 period, while 43.2% continued their service related to chronic wound care, and only 17.0% (n = 18) in the wound care service before the pandemic. These rates are 51.3% (n = 139), 51.6% (n = 157) and 36.8% (n = 128) for nurses, respectively. 40.7% of the physicians (n = 33) and 34.9% of the nurses (n = 106) stated that their time had been reduced for chronic wound care. When the telehealth experiences were examined, 32.4% (n = 24) of the physicians utilized telehealth, 29.7% (n = 22) used e-visit, 77.0% (n = 57) stated that they thought telehealth was a good option, 47.3% (n = 35) utilized it for wound evaluation and treatment, and 31.9% (n = 59) used smart phones. These rates for nurses were 16.6% (n = 45), 14.0% (n = 38), 72.7% (n = 197), 33.9% (n = 92), and 27.0% (n = 182), respectively.

CONCLUSIONS

The COVID-19 pandemic negatively affected the manner of delivery, duration, and quality of service regarding wound management. During this period, face-to-face contact times with patients were reduced, some diagnosis and treatment attempts were not performed, and wound care services were suspended temporarily or permanently. On the other hand, a positive result was achieved in that the physicians and nurses gave positive feedback for the telehealth experience.

Investigating the Use of Telemedicine for Digitally Mediated Delegation in Team-Based Primary Care: Mixed Methods Study

Background

Owing to the shortage of medical professionals, as well as demographic and structural challenges, new care models have emerged to find innovative solutions to counter medical undersupply. Team-based primary care using medical delegation appears to be a promising approach to address these challenges; however, it demands efficient communication structures and mechanisms to reinsure patients and caregivers receive a delegated, treatment-related task. Digital health care technologies hold the potential to render these novel processes effective and demand driven.

Objective

The goal of this study is to recreate the daily work routines of general practitioners (GPs) and medical assistants (MAs) to explore promising approaches for the digital moderation of delegation processes and to deepen the understanding of subjective and perceptual factors that influence their technology assessment and use.

Methods

We conducted a combination of 19 individual and group interviews with 12 GPs and 14 MAs, seeking to identify relevant technologies for delegation purposes as well as stakeholders’ perceptions of their effectiveness. Furthermore, a web-based survey was conducted asking the interviewees to order identified technologies based on their assessed applicability in multi-actor patient care. Interview data were analyzed using a three-fold inductive coding procedure. Multidimensional scaling was applied to analyze and visualize the survey data, leading to a triangulation of the results.

Results

Our results suggest that digital mediation of delegation underlies complex, reciprocal processes and biases that need to be identified and analyzed to improve the development and distribution of innovative technologies and to improve our understanding of technology use in team-based primary care. Nevertheless, medical delegation enhanced by digital technologies, such as video consultations, portable electrocardiograms, or telemedical stethoscopes, can counteract current challenges in primary care because of its unique ability to ensure both personal, patient-centered care for patients and create efficient and needs-based treatment processes.

Conclusions

Technology-mediated delegation appears to be a promising approach to implement innovative, case-sensitive, and cost-effective ways to treat patients within the paradigm of primary care. The relevance of such innovative approaches increases with the tremendous need for differentiated and effective care, such as during the ongoing COVID-19 pandemic. For the successful and sustainable adoption of innovative technologies, MAs represent essential team members. In their role as mediators between GPs and patients, MAs are potentially able to counteract patients’ resistance toward using innovative technology and compensate for patients’ limited access to technology and care facilities.

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

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

Scope, context and quality of telerehabilitation guidelines for physical disabilities: a scoping review

OBJECTIVE

To identify the available guidance and training to implement telerehabilitation movement assessments for people (adults and children) with a physical disability, including those recovering from COVID-19.

DESIGN

Rapid scoping review.

INCLUDED SOURCES AND ARTICLES

PubMed, CINAHL, PsychInfo, Cochrane, Embase, Web of Science, PEDro, UK Health Forum, WHO, National Archives and NHS England were searched using the participant-concept-context framework from 2015 to August 2020. Primary studies that recruited individuals with physical disabilities and guidance documents aimed at providers to implement movement-related telerehabilitation were included.

RESULTS

23 articles (11 primary research studies, 3 systematic reviews and 9 guidance documents) were included out of 7857 that were identified from the literature search. Two main issues were found: (1) telerehabilitation guidance (from both research studies and guidance documents) was not specific to movement-related assessment and (2) most primary research studies provided neither guidance nor training of movement-specific assessment to practitioners. Of the COVID-19 related guidance, two articles reported COVID-19 management that only referred to identifying COVID-19 status without references to specific movement-related guidance.

CONCLUSIONS

Telerehabilitation guidance and training have existed pre-COVID-19, yet the lack of specific movement-related information and provider support is surprising. This gap must be addressed to optimise effective implementation of remote assessments for those with physical disabilities.

REVIEW REGISTRATION

Open Science Framework: osf.io/vm6sp.

Virtual Cancer Care During the COVID-19 Pandemic in Alberta: Evidence From a Mixed Methods Evaluation and Key Learnings

PURPOSE

This study reports on a mixed methods evaluation conducted within a provincial cancer program in Alberta, Canada. The purpose was to capture key learnings from a rapid virtual care implementation because of the COVID-19 pandemic and to understand the impact on patient and staff experiences.

METHODS

Administrative data were collected for 21,362 patients who had at least one virtual or in-person visit to any provincial cancer center from April 1, 2020, to June 10, 2020. Patient surveys were conducted with 397 randomly selected patients who had received a virtual visit. Surveys were also conducted with 396 Cancer Care Alberta staff.

RESULTS

14,906 virtual visits took place in this period, and about 40% of weekly visits were virtual. Significant differences were observed in both patient-reported symptom questionnaire completion rates and referrals to supportive care services between patients seen in-person and virtually. Patients receiving active treatments reported significantly lower levels of satisfaction with virtual visits than those seen for follow-up, but overall 90% of patients indicated interest in receiving virtual care in the future. Staff thought virtual visits increased patients' access to care but less than one third (31.5%) felt confident meeting patients' emotional needs and having conversations about disease progression and/or end of life virtually.

CONCLUSION

The COVID-19 pandemic has driven the rapid implementation of virtual visits for cancer care delivery in health care settings. The findings from this mixed methods evaluation provide a concrete set of considerations for organizations looking to develop a large-scale, enduring virtual care strategy.

Patient preferences for use of virtual consultations in an orthopaedic rehabilitation setting: Results from a discrete choice experiment

Objective

Virtual Consultations may reduce the need for face-to-face outpatient appointments, thereby potentially reducing the cost and time involved in delivering health care. This study reports a discrete choice experiment (DCE) that identifies factors that influence patient preferences for virtual consultations in an orthopaedic rehabilitation setting.

Methods

Previous research from the CONNECT (Care in Orthopaedics, burdeN of treatmeNt and the Effect of Communication Technology) Project and best practice guidance informed the development of our DCE. An efficient fractional factorial design with 16 choice scenarios was created that identified all main effects and partial two-way interactions. The design was divided into two blocks of eight scenarios each, to reduce the impact of cognitive fatigue. Data analysis were conducted using binary logit regression models.

Results

Sixty-one paired response sets (122 subjects) were available for analysis. DCE factors (whether the therapist is known to the patient, duration of appointment, time of day) and demographic factors (patient qualifications, access to equipment, difficulty with activities, multiple health issues, travel costs) were significant predictors of preference. We estimate that a patient is less than 1% likely to prefer a virtual consultation if the patient has a degree, is without access to the equipment and software to undertake a virtual consultation, does not have difficulties with day-to-day activities, is undergoing rehabilitation for one problem area, has to pay less than £5 to travel, is having a consultation with a therapist not known to them, in 1 weeks’ time, lasting 60 minutes, at 2 pm. We have developed a simple conceptual model to explain how these factors interact to inform preference, including patients’ access to resources, context for the consultation and the requirements of the consultation.

Conclusions

This conceptual model provides the framework to focus attention towards factors that might influence patient preference for virtual consultations. Our model can inform the development of future technologies, trials, and qualitative work to further explore the mechanisms that influence preference.

'They're getting a taste of our world': A qualitative study of people with multiple sclerosis' experiences of accessing health care during the COVID-19 pandemic in the Australian Capital Territory

Background

People with multiple sclerosis (MS), who are often immunocompromised, require complex care and engage with a variety of health‐care providers to manage their health.

Objective

To elucidate people with MS' experiences of accessing health care during the COVID‐19 pandemic in Australia.

Design

A qualitative study involving semi‐structured interviews and thematic analysis.

Settings and participants

Eight adults with a clinical diagnosis of MS participated in telephone or video call interviews between June and July 2020.

Results

Participants were aware that having MS made them more vulnerable to contracting COVID‐19. In some cases, usual care was postponed or not sought. Some circumstances warranted the risk of a face‐to‐face consultation. Benefits of telehealth consultations included improved access, convenience and being contact‐free. In comparison with video consultations, those via telephone were considered less personal and limited capacity to read body language, and for physical examination. Most participants hoped to incorporate telehealth into their future health‐care routines.

Discussion and conclusion

Personal risk assessment and trust in health‐care professionals are determinants of the mode through which people with MS accessed health care during the COVID‐19 pandemic. Telehealth has been a valuable tool to mitigate COVID‐19 transmission through enabling contact‐free consultations. People with MS may find specific value in video consultations, which enable visualization of physical function. There is a need for training and support for all clinicians to conduct remote consultations.

Patient or public contribution

This study was conducted by a team comprised of four people with MS, a neurologist and four health services researchers.

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

OBJECTIVES

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring Nurse and Patient Experiences of Developing Rapport During Oncology Ambulatory Care Videoconferencing Visits: Protocol for a Qualitative Study

Background

Telehealth videoconferencing has largely been embraced by health care providers and patients during the COVID-19 pandemic; however, little is known about specific techniques for building rapport and provider-patient relationships in this care environment. Although research suggests that videoconferencing is feasible and can be effective for some types of care, concerns about the impact of technology on provider-patient relationships exist across health disciplines. Suggestions for adapting some in-person rapport techniques, such as the use of small talk, eye contact, and body language to facilitate trust, personal connection, and communication during videoconferencing encounters, have been discussed in the popular press and clinical commentaries. Notably, evidence regarding the effects of these strategies on rapport and clinical care outcomes is lacking. Understanding how to establish rapport in videoconferencing visits is especially important in oncology nursing, where rapport with patients enables nurses to become a source of emotional support, helping patients adapt and navigate the cancer journey.

Objective

This study aims to investigate the nature of nurse-patient rapport in ambulatory cancer care videoconferencing visits. The objectives include exploring how patients with cancer and nurses describe experiences of rapport and strategies for cultivating rapport in videoconferencing visits and similarities and differences identified by patients with cancer and nurses between experiences of rapport in videoconferencing and in-person visits.

Methods

Semistructured narrative interviews of patients with cancer and nurses will be conducted to understand the experience of rapport building in videoconferencing visits. Nurses and patients will be interviewed separately to facilitate an understanding of the perspectives of both types of participants. Interviews will be conducted on a secure videoconferencing platform. This qualitative descriptive study will describe participant experiences in a manner that, although not without interpretation, is as close to the data as possible. The research team will meet regularly to discuss, define, and document codes, categories, and themes, and the team will maintain a detailed audit trail of analytical decisions. In addition, member checking will enhance the rigor of the study. Nurse and patient interviews will be analyzed separately using identical procedures and may be explored side by side in the final analysis to provide a comparative analysis. Data management and analysis will be performed using NVivo 12.

Results

Data collection will begin during summer 2021, with results from the data analysis anticipated by winter 2021. A research team trained in qualitative methodology will use conventional content analysis to analyze the data using first- and second-level codes derived directly from the transcribed text data.

Conclusions

This study aims to determine what behaviors, communication techniques, and relational practices need to be adapted in videoconferencing telehealth visits, setting the foundation for future development of interventions and evidence-based practice guidelines for relationship building during videoconferencing telehealth visits.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27940

Physicians' Attitudes Toward Telemedicine Consultations During the COVID-19 Pandemic: Cross-sectional Study

Background

To mitigate the effect of the COVID-19 pandemic, health care systems worldwide have implemented telemedicine technologies to respond to the growing need for health care services during these unprecedented times. In the United Arab Emirates, video and audio consultations have been implemented to deliver health services during the pandemic.

Objective

This study aimed to evaluate whether differences exist in physicians’ attitudes and perceptions of video and audio consultations when delivering telemedicine services during the COVID-19 pandemic.

Methods

This survey was conducted on a cohort of 880 physicians from outpatient facilities in Abu Dhabi, which delivered telemedicine services during the COVID-19 pandemic between November and December 2020. In total, 623 physicians responded (response rate=70.8%). The survey included a 5-point Likert scale to measure physician’s attitudes and perceptions of video and audio consultations with reference to the quality of the clinical consultation and the professional productivity. Descriptive statistics were used to describe physicians’ sociodemographic characteristics (age, sex, designation, clinical specialty, duration of practice, and previous experience with telemedicine) and telemedicine modality (video vs audio consultations). Regression models were used to assess the association between telemedicine modality and physicians’ characteristics with the perceived outcomes of the web-based consultation.

Results

Compared to audio consultations, video consultations were significantly associated with physicians’ confidence toward managing acute consultations (odds ratio [OR] 1.62, 95% CI 1.2-2.21; P=.002) and an increased ability to provide patient education during the web-based consultation (OR 2.21, 95% CI 1.04-4.33; P=.04). There was no significant difference in physicians’ confidence toward managing long-term and follow-up consultations through video or audio consultations (OR 1.35, 95% CI 0.88-2.08; P=.17). Video consultations were less likely to be associated with a reduced overall consultation time (OR 0.69, 95% CI 0.51-0.93; P=.02) and reduced time for patient note-taking compared to face-to-face visits (OR 0.48, 95% CI 0.36-0.65; P<.001). Previous experience with telemedicine was significantly associated with a lower perceived risk of misdiagnosis (OR 0.46, 95% CI 0.3-0.71; P<.001) and an enhanced physician-patient rapport (OR 2.49, 95% CI 1.26-4.9; P=.008).

Conclusions

These results indicate that video consultations should be adopted frequently in the new remote clinical consultations. Previous experience with telemedicine was associated with a 2-fold confidence in treating acute conditions, less than a half of the perceived risk of misdiagnosis, and an increased ability to provide patients with health education and enhance the physician-patient rapport. Additionally, these results show that audio consultations are equivalent to video consultations in providing remote follow-up care to patients with chronic conditions. These findings may be beneficial to policymakers of e-health programs in low- and middle-income countries, where audio consultations may significantly increase access to geographically remote health services.

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

Introduction

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

Purpose

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

Findings

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

Conclusions

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

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

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