GP perceptions of telehealth services in Australia: a qualitative study

Tailoring communication practices to support effective delivery of telehealth in general practice

BACKGROUND

The unprecedented increase in telehealth use due to COVID-19 has changed general practitioners' (GP) and patients' engagement in healthcare. There is limited specific advice for effective communication when using telehealth. Examining telehealth use in practice in conjunction with perspectives on telehealth as they relate to communication allows opportunities to produce evidence-based guidance for optimal use of telehealth, while also offering practitioners the opportunity to reflect on elements of their communicative practice common to both styles of consultation. The objective of this research was to develop evidence-based resources to support effective, person-centred communication when GPs and patients use telehealth. This included examination of interactional practices of recorded telehealth consultations, exploration of GP and patient perspectives relating to telehealth, and identifying priorities for guidance informed by these analyses as well as participant co-design.

METHODS

This study involved recording telehealth consultations (n = 42), conducting patient surveys (n = 153), and interviewing patients (n = 9) and GPs (n = 15). These were examined using interaction analytic methods, quantitative analysis, and thematic analyses, to create a robust, integrated picture of telehealth practice and perspectives. The process of research translation involved a co-design approach, engaging with providers, patients, and policy makers to facilitate development of evidence-based principles that focus on supporting effective communication when using telehealth.

RESULTS

Three key themes relating to communication in telehealth were identified across the different analyses. These were relationship building, conversational flow, and safety netting. The draft best practice principles drawn from these themes were modified based on co-design feedback into five Best Practice Principles for Communication between GPs and Patients using Telehealth.

CONCLUSIONS

Effective communication is supported through relationship building and attention to conversational flow in telehealth consultations, which in turn allows for safety netting to occur. In telehealth, GPs and patients recognise that not being co-present changes the consultation and use both intuitive and strategic interactional adjustments to support their exchange. The mixed-method examination of experiences through both a detailed analysis of telehealth consultations in practice and comparative exploration of GP and patient perspectives enabled the identification of principles that can support effective communication when using telehealth. Co-design helped ensure these principles are ready for implementation into practice.

General practitioner preferences for telehealth consultations in Australia: a pilot survey and discrete choice experiment

AIM

To identify and quantify general practitioner (GP) preferences related to service attributes of clinical consultations, including telehealth consultations, in Australia.

BACKGROUND

GPs have been increasingly using telehealth to deliver patient care since the onset of the 2019 coronavirus disease (COVID-19) pandemic. GP preferences for telehealth service models will play an important role in the uptake and sustainability of telehealth services post-pandemic.

METHODS

An online survey was used to ask GPs general telehealth questions and have them complete a discrete choice experiment (DCE). The DCE elicited GP preferences for various service attributes of telehealth (telephone and videoconference) consultations. The DCE investigated five service attributes, including consultation mode, consultation purpose, consultation length, quality of care and rapport, and patient co-payment. Participants were presented with eight choice sets, each containing three options to choose from. Descriptive statistics was used, and mixed logit models were used to estimate and analyse the DCE data.

FINDINGS

A total of 60 GPs fully completed the survey. Previous telehealth experiences impacted direct preferences towards telehealth consultations across clinical presentations, although in-person modes were generally favoured (in approximately 70% of all scenarios). The DCE results lacked statistical significance which demonstrated undiscernible differences between GP preferences for some service attributes. However, it was found that GPs prefer to provide a consultation with good quality care and rapport (P < 002). GPs would also prefer to provide care to their patients rather than decline a consultation due to consultation mode, length or purpose (P < 0.0001). Based on the findings, GPs value the ability to provide high-quality care and develop rapport during a clinical consultation. This highlights the importance of recognising value-based care for future policy reforms, to ensure continued adoption and sustainability of GP telehealth services in Australia.

Adapting telehealth to address health equity: Perspectives of primary care providers across the United States

BACKGROUND

Telehealth has the potential to increase access to care for medically underserved patients. This qualitative study aimed to identify telecare practices used during the COVID-19 pandemic to meet the needs of patients experiencing homelessness, patients with disabilities, and patients with language preference other than English (LOE).

METHODS

We conducted a secondary qualitative data analysis of 47 clinician interviews at Federally Qualified Health Centers (FQHCs) around the country. Using thematic analysis, transcripts were coded by line-by-line by five qualitative researchers. A multidisciplinary team of telehealth experts, researchers and primary care clinicians reviewed memos and excerpts to generate major themes.

RESULTS

We identified six main areas demonstrating how community providers developed strategies or practices to improve access to care for vulnerable patients: reaching patients experiencing homelessness, serving deaf and hard of hearing patients, improving access for patients with disabilities, serving patients with LOE, improving access for mental and behavioral health services, and educating patients about telehealth. During the pandemic, FQHCs developed innovative solutions to provide access to care for the unhoused, including using telehealth in shelters, vans, and distributing devices like mobile phones and tablets. Telehealth reduced transportation burdens for patients with disabilities and reduced no-show rates for mental health services by adapting group therapy via telehealth features (like break-out rooms) and increasing provider capacity.

CONCLUSION

Our study identified strategies adopted by FQHCs to serve underserved populations during the COVID-19 pandemic. Our findings highlight the need for enduring strategies to improve health equity through telehealth..

Telemedicine in specialist outpatient care during COVID-19: a qualitative study

BACKGROUND

COVID-19 accelerated healthcare changes, introducing various telehealth services. Work is needed to determine the suitability of telemedicine in the post-pandemic era.

AIMS

To explore perceptions and experiences of telemedicine among patients and providers (clinicians and health administrators) who were involved in telemedicine appointments in hospital outpatient clinics in 2020-2022.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study: semi-structured interviews were conducted with 37 participants (16 patients and 21 providers) in various hospital specialist outpatient clinics in a New South Wales local health district.

RESULTS

Patients were generally satisfied with telemedicine consultations, especially during COVID restrictions, because of the convenience of accessing care from home and minimising the risk of COVID exposure. However, patients considered that the inability to receive a physical examination was a significant disadvantage of telemedicine. Providers had ambivalent perceptions and expressed concerns about mis- and under-diagnoses because of the inability to conduct physical examinations. They considered telemedicine suitable for review appointments but noted an associated increased workload and stressed the need for sustainable funding models (Medicare items). Both patients and providers recognised the need for education/training and better integration of telemedicine platforms into existing infrastructure to facilitate an optimal hybrid model of care.

CONCLUSION

Despite expressing some concerns over its limitations, patients valued telemedicine for its convenience and for meeting their needs during the pandemic. While acknowledging that patients experienced some benefits from telemedicine, clinicians expressed concerns about potential missed diagnoses, uncertain clinical outcomes and lack of administrative and technological infrastructure. The ultimate test of telemedicine will be its impact on clinical outcomes versus longstanding models of in-person care.

Telepsychiatry in Australia: A Scoping Review

Telepsychiatry formed part of the Australian mental health response to COVID-19, but relevant reviews pre- and post-pandemic are sparse. This scoping review aimed to map the literature on telepsychiatry in Australia and identify key research priorities. We searched databases (Medline, PubMed, PsycINFO, Scopus, Web of Science, EBSCO Psychology & Behavioral Sciences Collection, Proquest databases, and Cochrane Central Register of Controlled Trials) and reference lists from January 1990 to December 2022. Keywords included telepsychiatry, videoconferencing, telephone consultation, psychiatry, mental health, and Australia. Two reviewers independently screened titles, abstracts, and full texts. We identified 96 publications, one-third of which appeared since 2020. Extracted data included article types, service types, usage levels, outcome measures, perceptions, and research gaps. Most publications were quantitative studies (n = 43) and narrative reports of services (n = 17). Seventy-six papers reported mostly publicly established services. Videoconferencing alone was the most common mode of telepsychiatry. There was increased use over time, with the emergence of metropolitan telepsychiatry during the pandemic. Few papers used validated outcome measures (n = 5) or conducted economic evaluations (n = 4). Content analysis of the papers identified perceptions of patient (and caregiver) benefits, clinical care, service sustainability, and technology capability/capacity. Benefits such as convenience and cost-saving, clinical care issues, and implementation challenges were mentioned. Research gaps in patient perspectives, outcomes, clinical practice, health economics, usage patterns, and technological issues were identified. There is consistent interest in, and growth of, telepsychiatry in Australia. The identified perception themes might serve as a framework for future research on user perspectives and service integration. Other research areas include usage trends, outcome measures, and economic evaluation.

Drivers of telemedicine in primary care clinics at a large academic medical centre

BACKGROUND

COVID-19 disrupted healthcare routines and prompted rapid telemedicine implementation. We investigated the drivers of visit modality selection (telemedicine versus in-person) in primary care clinics at an academic medical centre.

METHODS

We used electronic medical record data from March 2020 to May 2022 from 13 primary care clinics (N = 21,031 new, N = 207,292 return visits), with 55% overall telemedicine use. Hierarchical logistic regression and cross-validation methods were used to estimate the variation in visit modality explained by the patient, clinician and visit factors as measured by the mean-test area under the curve (AUC).

RESULTS

There was significant variation in telemedicine use across clinicians (ranging from 0-100%) for the same visit diagnosis. The strongest predictors of telemedicine were the clinician seen for new visits (mean AUC of 0.79) and the primary visit diagnosis for return visits (0.77). Models based on all patient characteristics combined accounted for relatively little variation in modality selection, 0.54 for new and 0.58 for return visits, respectively. Amongst patient characteristics, males, patients over 65 years, Asians and patient's with non-English language preferences used less telemedicine; however, those using interpreter services used significantly more telemedicine.

CONCLUSION

Clinician seen and primary visit diagnoses were the best predictors of visit modality. The distinction between new and return visits and the minimal impact of patient characteristics on visit modality highlights the complexity of clinical care and warrants research approaches that go beyond linear models to uncover the emergent causal effects of specific technology features mediated by tasks, people and organisations.

The Role of a Smart Health Ecosystem in Transforming the Management of Chronic Health Conditions

The effective management of chronic conditions requires an approach that promotes a shift in care from the clinic to the home, improves the efficiency of health care systems, and benefits all users irrespective of their needs and preferences. Digital health can provide a solution to this challenge, and in this paper, we provide our vision for a smart health ecosystem. A smart health ecosystem leverages the interoperability of digital health technologies and advancements in big data and artificial intelligence for data collection and analysis and the provision of support. We envisage that this approach will allow a comprehensive picture of health, personalization, and tailoring of behavioral and clinical support; drive theoretical advancements; and empower people to manage their own health with support from health care professionals. We illustrate the concept with 2 use cases and discuss topics for further consideration and research, concluding with a message to encourage people with chronic conditions, their caregivers, health care professionals, policy and decision makers, and technology experts to join their efforts and work toward adopting a smart health ecosystem.

Nursing practice and teleconsultations in a pandemic context: A mixed-methods study

AIM

To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic.

BACKGROUND

Teleconsultation use increased rapidly during the COVID-19 pandemic. Its implementation has been documented for physicians and specialists, but knowledge is still limited in nursing practice.

DESIGN

A sequential mixed-methods study.

METHODS

Phase 1: A cross-sectional e-survey with 98 nurses (64 nurse clinicians [NCs] and 34 nurse practitioners [NPs]) was conducted in 2020 in 48 teaching primary care clinics in Quebec (Canada). Phase 2: Semi-structured interviews with four NCs and six NPs were conducted in 2021 in three primary care clinics. This study adheres to STROBE and COREQ guidelines.

RESULTS

During the pandemic, telephone was the principal teleconsultation modality used by NPs and NCs compared to other teleconsultation modalities (text messages, email and video). The only variable associated with a higher likelihood of using teleconsultations was type of professional (NCs). Video consultation was almost absent from the modalities used. The majority of participants reported several facilitators to using teleconsultations in their work (e.g. web platforms and work-family balance) and for patients (e.g. rapid access). Some barriers to utilisation were identified (e.g. lack of physical resources) for successful integration of teleconsultations at the organisational, technological and systemic levels. Participants also reported positive (e.g. assessment of cognitive deficiency) and negative (e.g. rural population) impacts of using teleconsultations during a pandemic that made the use of teleconsultations complex.

CONCLUSION

This study highlights the potential for nurses to use teleconsultations in primary care practice and suggests concrete solutions to encourage their implementation after the pandemic.

RELEVANCE TO CLINICAL PRACTICE

Findings emphasize the need for updated nursing education, easy-to-use technology and the strengthening of policies for the sustainable use of teleconsultations in primary health care.

IMPLICATIONS FOR THE PROFESSION

This study could promote the sustainable use of teleconsultations in nursing practice.

REPORTING METHOD

The study adhered to relevant EQUATOR guidelines; the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as the study focused on the use of teleconsultation among health professionals, specifically primary care nurses.

Equity in virtual care: A mixed methods study of perspectives from physicians

BACKGROUND

Virtual care expanded rapidly during the COVID-19 pandemic, and how this shift affected healthcare disparities among subgroups of patients is of concern. Racial and ethnic minorities, older adults, individuals with less education, and lower-income households have lower rates of home broadband, smartphone ownership, and patient portal adoption, which may directly affect access to virtual care. Because primary care is a major access point to healthcare, perspectives of primary care providers are critical to inform the implementation of equitable virtual care.

OBJECTIVE

The aim of this mixed methods study was to explore primary care physician experiences and perceptions of barriers and facilitators to equitable virtual care.

DESIGN

We used an explanatory sequential mixed methods design, which consists of first collecting and analyzing quantitative survey data, then using those results to inform a qualitative follow-up phase to explain and expand on results.

PARTICIPANTS

Primary care physicians in a family medicine department at an academic medical center responded to surveys (n = 38) and participated in interviews (n = 16).

APPROACH

Participants completed a survey concerning frequency and preferences about video visits, pros and cons of video visits, communication aspects, and sufficiency of the technology. A purposeful sample of participants completed semi-structured interviews about their virtual care experiences with a focus on equity for subpopulations.

KEY RESULTS

The results indicated that physicians have observed equity issues for unique patient populations. The results add to the understanding of nuanced ways in which virtual care can increase and decrease healthcare access for unique populations. Patients with limited English proficiency were particularly affected by inequity in virtual care access.

CONCLUSION

Additional research and interventions are needed to improve portal access for those with limited English proficiency. Improvements should focus on health system interventions that expand access without requiring increased patient burden.

Telehealth's future in Australian primary health care: a qualitative study exploring lessons learnt from the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, telehealth emerged as a means of safely providing primary healthcare (PHC) consultations. In Australia, changes to telehealth funding led to the reconsideration of the role of telehealth in the ongoing provision of PHC services.

AIM

To investigate GPs', registered nurses' (RNs), nurse practitioners' (NPs), and allied health (AH) clinicians perceptions of the sustainability of telehealth in PHC post-pandemic.

DESIGN & SETTING

Semi-structured interviews were undertaken with 33 purposively selected clinicians, including GPs (n = 13), RNs (n = 5), NPs (n = 9), and AH clinicians (n = 6) working in PHC settings across Australia. Participants were drawn from responders to a national survey of PHC providers (n = 217).

METHOD

The thematic analysis approach reported by Braun and Clarke was used to analyse the interview data.

RESULTS

Data analysis revealed that the perception of providers was represented by the following two themes: lessons learnt; and the sustainability of telehealth. Lessons learnt included the need for rapid adaptation to telehealth, use of technology, and the pandemic being a catalyst for long-term change. The sustainability of telehealth in PHC comprised four subthemes around challenges: the funding model, maintaining patient and provider safety, hybrid service models, and access to support.

CONCLUSION

Providers required resilience and flexibility to adapt to telehealth. Funding models must reward providers from an outcome focus, rather than placing limits on telehealth's use. Hybrid approaches to service delivery will best meet the needs of the community but must be accompanied by support and education for PHC professionals.

Telehealth use in Australian primary healthcare during COVID-19: a cross-sectional descriptive survey

OBJECTIVE

This study aimed to investigate Australian primary healthcare professionals' experiences of the rapid upscaling of telehealth during COVID-19.

DESIGN

A cross-sectional survey.

PARTICIPANTS AND SETTING

Two hundred and seventeen general practitioners, nurses and allied health professionals employed in primary healthcare settings across Australia were recruited via social media and professional organisations.

METHODS

An online survey was disseminated between December 2020 and March 2021. The survey comprised items about individual demographics, experiences of delivering telehealth consultations, perceived quality of telehealth consultations and future perceptions of telehealth.

RESULTS

Telephone was the most widely used method of providing telehealth, with less than 50% of participants using a combination of telephone and video. Key barriers to telehealth use related to the inability to undertake physical examination or physical intervention. Telehealth was perceived to improve access to healthcare for some vulnerable groups and those living in rural settings, but reduced access for people from non-English-speaking backgrounds. Quality of telehealth care was considered mostly or somewhat the same as care provided face-to-face, with actual or perceived negative outcomes related to missed or delayed diagnosis. Overwhelmingly, participants wanted telehealth to continue with guaranteed ongoing funding. Some 43.7% of participants identified the need to further improve telehealth models of care.

CONCLUSION

The rapid shift to telehealth has facilitated ongoing care during the COVID-19 pandemic. However, further work is required to better understand how telehealth can be best harnessed to add value to service delivery in usual care.

Cancer care and management during COVID-19: A comparison of in-person, video and telephone consultations

In Australia, the COVID-19 pandemic has resulted in the exponential growth in the delivery of telehealth services. Medicare data indicates that the majority of telehealth consultations have used the telephone, despite the known benefits of using video. The aim of this study was to understand the perceived quality and effectiveness of in-person, telephone and videoconsultations for cancer care. Data was collected via online surveys with consumers (n = 1162) and health professionals (n = 59), followed by semi-structured interviews with telehealth experienced health professionals (n = 22) and consumers (n = 18). Data were analysed using descriptive statistics and significance was tested using the chi-square test. A framework analysis and thematic analysis were used for qualitative data. Results indicate telehealth is suitable for use across the cancer care pathway. However, consumers and health professionals perceived videoconsultations facilitated visual communication and improved patients' quality of care. The telephone was appropriate for short transactional consultations such as repeat prescriptions. Consumers were rarely given the choice of consultation modality. The choice of modality depended on a range of factors such as the type of consultation and stage of cancer care. Hybrid models of care utilising in-person, video and telephone should be developed and requires further guidance to promote the adoption of telehealth in cancer care.

Costs to the Medicare Benefits Schedule for general practitioner consultations: A time-series analysis

The COVID-19 pandemic was a catalyst for the introduction of additional telehealth funding (telehealth item numbers) for general practitioner (GP) consultations through the Medicare Benefits Schedule (MBS) in Australia. This study evaluated the impact of telehealth funding on costs to the MBS for GP consultations from January 2017 to December 2021. An interrupted time series analysis assessed MBS costs (initial and monthly growth) for GP consultations (in-person, videoconference, telephone) before and after additional telehealth item numbers were introduced. From January 2017 to February 2020, total MBS costs for GP consultations were, on average, $545 million per month compared to $592 million per month from March 2020 to December 2021. There was an initial cost increase of approximately $39 million in the first month after additional telehealth funding was introduced ( p = 0.0001). Afterwards, there was no significant change in monthly costs ( p = 0.539). The introduction of additional MBS telehealth funding increased overall MBS costs for GP consultations. This increased cost for GP telehealth services could save costs to society if it translates into improved continuity of care, decreased hospitalisations, reduced productivity losses and improved patient outcomes. Future policy reform should incorporate a cost–benefit analysis to determine if increased MBS costs for GP consultations are a good investment.

Visit Types in Primary Care With Telehealth Use During the COVID-19 Pandemic: Systematic Review

BACKGROUND

Telehealth was rapidly incorporated into primary care during the COVID-19 pandemic. However, there is limited evidence on which primary care visits used telehealth.

OBJECTIVE

The objective of this study was to conduct a systematic review to assess what visit types in primary care with use of telehealth during the COVID-19 pandemic were reported; for each visit type identified in primary care, under what circumstances telehealth was suitable; and reported benefits and drawbacks of using telehealth in primary care during the COVID-19 pandemic.

METHODS

This study was a systematic review using narrative synthesis. Studies were obtained from four databases (Ovid [MEDLINE], CINAHL Complete, PDQ-Evidence, and ProQuest) and gray literature (NSW Health, Royal Australian College of General Practitioners guidelines, and World Health Organization guidelines). In total, 3 independent reviewers screened studies featuring telehealth use during the COVID-19 pandemic in primary care. Levels of evidence were assessed according to the Grading of Recommendations Assessment, Development, and Evaluation. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. Benefits and drawbacks of telehealth were assessed according to the National Quality Forum Telehealth Framework.

RESULTS

A total of 19 studies, predominately cross-sectional surveys or interviews (13/19, 68%), were included. Seven primary care visit types were identified: chronic condition management (17/19, 89%), existing patients (17/19, 89%), medication management (17/19, 89%), new patients (16/19, 84%), mental health/behavioral management (15/19, 79%), post-test result follow-up (14/19, 74%), and postdischarge follow-up (7/19, 37%). Benefits and drawbacks of telehealth were reported across all visit types, with chronic condition management being one of the visits reporting the greatest use because of a pre-existing patient-provider relationship, established diagnosis, and lack of complex physical examinations. Both patients and clinicians reported benefits of telehealth, including improved convenience, focused discussions, and continuity of care despite social distancing. Reported drawbacks included technical barriers, impersonal interactions, and semi-established reimbursement models.

CONCLUSIONS

Telehealth was used for different visit types during the COVID-19 pandemic in primary care, with most visits for chronic condition management, existing patients, and medication management. Further research is required to validate our findings and explore the long-term impact of hybrid models of care for different visit types in primary care.

TRIAL REGISTRATION

PROSPERO CRD42022312202; https://tinyurl.com/5n82znf4.

General practice perspective on the use of telehealth during the COVID-19 pandemic in Australia using an Action Research approach: a qualitative study

OBJECTIVES

Telehealth has emerged as a viable and safe mode of care delivery in Australia during the COVID-19 pandemic. However, electronic general practice data reveal differences in uptake and consultation mode, which we hypothesise may be due to potential barriers impacting on quality of care. We aimed to identify the benefits and barriers of telehealth use in general practice, using an 'Action Research' approach involving general practitioners (GPs) and general practice stakeholders.

DESIGN

Qualitative focus group performed within a broader Action Research methodology.

SETTING

A focus group was held in August 2021, with general practice participants from Victoria, Australia.

PARTICIPANTS

The study consisted of a purposive sample of 11 participants, including GPs (n=4), representatives from three primary health networks (n=4) and data custodian representatives (n=3) who were part of a project stakeholder group guided by an Action Research approach.

METHODS

Semistructured interview questions were used to guide focus group discussions via videoconference, which were recorded and transcribed verbatim for analysis. The transcript was analysed using an inductive thematic approach.

RESULTS

Emerging themes included evolution of telehealth, barriers to telehealth (privacy, eligibility, technology, quality of care, sociodemographic and residential aged care barriers) and benefits of telehealth (practice, quality of care, sociodemographic and residential aged care benefits).

CONCLUSION

The findings highlight a range of barriers to telehealth that impact general practice, but also provide justification for the continuation and development of telehealth. These results provide important context to support data-driven population-based findings on telehealth uptake. They also highlight areas of quality improvement for the enhancement of telehealth as a valuable tool for routine general practice patient care.