Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

Healthcare professional views of a diabetes review postal box: A qualitative study

BACKGROUND

Non-attendance at diabetes appointments is common, 1-4 and associated with higher HbA1c levels, reduced medication taking, and increased complications. 1-45 Barriers to attendance are multifactorial including both logistical and psychosocial factors. 6-11 A proposed solution is the implementation of a postal diabetes annual review box enabling self-collection of blood and urine samples, and measurement of blood pressure and weight.

AIM

To explore the views of Healthcare Professionals (HCPs) who are involved in the organisation or delivery of diabetes care regarding the acceptability and implementation of a postal box as part of the diabetes annual review.

METHOD

We conducted a qualitative study recruiting HCPs into semi-structured interviews and focus groups. Collected data were analysed using an inductive approach and following the principles of reflexive thematic analysis12.

RESULTS

Twenty-one HCPs participated in the study. HCPs felt that a postal box could overcome many individual and service factors contributing to non-attendance. They felt the box could encourage self-management behaviours and could be used as a tool for communication. HCPs recognised that the postal box could free up time in appointments to focus on holistic care delivery without further stretching limited resources. HCPs were concerned about the possible additional administrative burden a postal box might create, and the public perception of an intervention which could reduce face-to-face care.

CONCLUSION

Healthcare professionals seem receptive to the idea of a postal diabetes annual review box and feel it has the potential to offer people with diabetes an improved quality of care.

Patient-facing online triage tools and clinician decision-making: a systematic review

OBJECTIVE

To evaluate the role of using outputs from patient-facing online triage tools in clinical decision-making in primary care.

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Scopus were searched for literature published between 1 January 2002 and 31 December 2022 and updated for literature published up to end of November 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of any design are included where the study investigates how primary care clinicians make clinical decisions in response to patient concerns reported using online triage tools.

DATA EXTRACTION AND SYNTHESIS

Data were extracted, and quality assessment was conducted using the Mixed Methods Appraisal Tool. Narrative synthesis was used to analyse the findings.

RESULTS

14 studies were included, which were conducted in the UK (n=9), Sweden (n=3) and Spain (n=2). There were no studies that examined clinical decision-making as an outcome. Outcomes relating to the impact on clinical decision-making were grouped into three categories: patient clinical outcomes (n=9), primary care practitioner experience (n=11) and healthcare system outcomes (n=14). Studies reported faster clinical decisions made in response to patient concerns. Other studies reported clinicians offering unnecessary urgent appointments as patients learnt to 'game' the system. Clinicians felt confident managing patient requests as they can access additional information (such as a photo attachment). Moreover, clinicians' time was freed up from appointments with limited clinical value. Contrarily, online triage was perceived as an additional step in the workflow.

CONCLUSION

Clinicians should be aware that their decision-making processes are likely to differ when using online triage tools. Developers can use the findings to improve the usability of the tools to aid clinical decision-making. Future research should focus on patient-facing online triage tools in general practice and the process of clinical decision-making.

PROSPERO REGISTRATION NUMBER

CRD42022373944.

Inter-rater reliability of Centor score assessments between telemedicine and in-person examinations in patients with an acute sore throat

BACKGROUND

It is uncertain whether the Centor criteria can be reliably assessed during telemedicine encounters with patients seeking care for a sore throat. Acquiring this knowledge is important as sore throat is a common reason for telemedicine consultations.

OBJECTIVES: PRIMARY OBJECTIVE

To compare the inter-rater reliability of Centor score assessments via telemedicine versus in-person examinations. Secondary objectives: To investigate whether the interrater reliability varies when assessing patients who are children versus adults, and whether the telemedicine physician considered conditions for assessment as adequate.

METHODS

A cross-sectional study in which each patient initially underwent a telemedicine evaluation, followed by an in-person assessment conducted by an independent physician who was kept unaware of the outcome of the initial evaluation. Agreement between both assessments was measured using Cohen's kappa coefficient.

RESULTS

During 2020-2023 189 patients with a mean age of 31 years (SD 18) were included. Among them, 114 were female and 148 adults. Agreement was low with kappa between 0.47(95% CI 0.38 - 0.56) to 0.58 (95% CI 0.43-0.72) when comparing assessments of lymph nodes, tonsils and the total Centor score. Kappa was potentially acceptable for history of fever and absence of cough. Subgrouping participants into children and adults did not affect kappa of the total Centor score.

CONCLUSION

Telemedicine examination in patients with an acute sore throat is not reliable for assessing Centor criteria.

The Dynamics of Doctor-Patient Communication During Remote Consultations: Qualitative Study Among Norwegian Contract General Practitioners

BACKGROUND

Patient consultations in general practice are undergoing a digital transformation, embracing diverse modalities such as video, text-based, and telephone consultations. The quality of communication in medical consultations is pivotal for successful outcomes, necessitating a comprehensive assessment of the impact of this transformation on doctor-patient communication and interaction.

OBJECTIVE

This study aims to explore general practitioners' (GPs') perspectives on how the communication between Norwegian contract GPs and patients has been affected by the large-scale implementation of remote consultations following the onset of the COVID-19 pandemic.

METHODS

Five focus groups, comprising 18 purposefully recruited GPs from diverse settings and geographical regions in Norway, were carried out in 2022. We applied thematic analysis guided by the framework proposed by Braun and Clarke.

RESULTS

Six themes resulted from the analysis. First, suitability regarding remote communication is context-dependent: knowing the characteristics of the patient as a person and the clinical relationship is more important than the reason for contact or type of health problem-even more so than during ordinary physical consultations. Second, remote consultations favor a demarcated communication style, "keeping things simple-the one-problem approach," which can increase work effectiveness. Third, a downside of such effective minimalism is that the uncritical use of remote consultations may undermine the quality of care. Communication becomes too transactional, limiting the chances of addressing more implicit and complex issues, with the risk of missing vital information. Fourth, remote modalities can help engage hesitant and vulnerable patients. Fifth, GPs make communicative trade-offs in the name of continuity to be able to maintain relationships with patients they see as vulnerable or fugitive. Finally, there are advantages and dilemmas stemming from text-based consultations. Although they offer benefits such as multimedia-enabled patient expression and sharing of digital information, some concerns include the risk of information loss through triage errors, managing informal language, and ending chat-like interactions between patients and doctors.

CONCLUSIONS

The implementation of remote consultations has many effects on clinical interaction and communication. Although these modalities can enhance efficiency, there is a discernible risk of compromised retrieval of essential information and unvoiced problems, potentially resulting in unintended consequences. The preservation of continuity of care emerges as a pivotal strategy to mitigate some of these challenges.

A theory-based analysis of the implementation of online asynchronous telemedicine platforms into primary care practices using Normalisation Process Theory

BACKGROUND

Online asynchronous telemedicine platforms are effective and have been implemented in primary care practices, but it is unclear whether implementation was successful. Implementation has not been studied on a large scale in primary care practice. Normalisation Process Theory is a sociological theory used to understand how complex practices can be embedded into routine practice. We aimed to identify and evaluate factors affecting, and make recommendations for, implementation of online asynchronous telemedicine platforms in primary care practice using Normalisation Process Theory.

METHODS

A systematic search was carried out across four databases. Studies included were empirical research, published between January 2015 and November 2022, of qualitative, quantitative and mixed methods designs, focusing on implementation of online asynchronous telemedicine platforms designed for two-way secure communication between patients and healthcare professionals to give or receive medical advice in primary care. Data extraction was guided by the domains of Normalisation Process Theory: context, mechanisms, outcomes.

RESULTS

25 reports from 21 primary studies were obtained. COVID-19 changed the context in which asynchronous platforms were implemented into primary care, due to restrictions on face-to-face contact. Coherence is supported by online platforms providing benefits for patients. Healthcare staff felt confident using platforms and better teamworking added to cognitive participation, however patient 'misuse' of platforms hindered this. Collective action was negatively affected by poor usability and integration of platforms into practice systems. Reflexive action through large- and small-scale studies had allowed improvements to be made, but poor response rates inhibit this. Outcomes include changed roles and responsibilities for staff and patients and high patient satisfaction. There are concerns regarding confidentiality and health inequities.

CONCLUSIONS

Increased workload, lack of integration into existing systems and poor usability affect implementation. Widespread implementation of online platforms in primary care practices can be supported by policy-makers through consistent guidelines to improve platforms' content, functionality and compatibility with clinical systems to try to enable improvements in practice. Further research should explore patient groups or needs for which online platforms are most suitable, reasons why online platforms work better for different patients and how different patient groups can be supported to benefit from asynchronous telemedicine.

Patients' Use of e-Consultations as an Alternative to Other General Practitioner Services: Cross-Sectional Survey Study

BACKGROUND

e-Consultations, defined as asynchronous text-based messaging, have transformed how patients interact with their general practitioner (GP). While e-consultations can improve patient access to GP care, concerns about increased workload for GPs are raised.

OBJECTIVE

This study aimed to address three research questions: (1) For what purpose and with what expectations do patients initiate e-consultations? (2) If e-consultations had not been available, what alternative actions would the patient have taken? and (3) How are the alternative actions associated with patient and e-consultation characteristics?

METHODS

A cross-sectional study was conducted through a web-based survey on Helsenorge. Helsenorge is the national citizen portal for digital health services in Norway, including e-consultations with the GP. All users who sent e-consultations through Helsenorge were invited to participate between January and February 2023. The survey addressed questions on users' expectations and experience with e-consultations. The association between patient and e-consultation characteristics and alternative actions to e-consultations were analyzed using multinomial logistic regression.

RESULTS

Overall, 13,011 users answered the survey. The most common reason for initiating an e-consultation was requesting a sick certificate (4940/13,011, 38%). Overall, 68.7% (8802/13,011) of respondents expected an answer within 24 hours, and 17.7% (2310/13,011) anticipated that the GP would ask them to attend a physical examination. If e-consultations had not been available, 45.5% (5917/13,011) of respondents would have booked a GP appointment, and 44.9% (5846/13,011) would have called the front desk. Users who expected a quicker response (odds ratio [OR] 1.64, 95% CI 1.46-1.85) and were less concerned about their health issues (OR 1.29, 95% CI 1.18-1.40) were more likely to call the front desk. Only 2.5% (323/13,011) of respondents would have contacted out-of-hours services. Users with longer travel time to the GP office (OR 6.08, 95% CI 3.46-10.66) and with a new health problem (OR 2.71, 95% CI 2.09-3.51) were more likely to choose this option. In addition, 4.7% (609/13,011) of the users would not have sought help if e-consultations had not been available. Younger patients (OR 2.16, 95% CI 1.38-3.37) and those with a longer travel time to the GP office (OR 2.19, 95% CI 1.27-3.80) or a new health issue (OR 1.74, 95% CI 1.43-2.12) had higher odds for not seeking help.

CONCLUSIONS

e-Consultations were often the patients' first choice of access route, and users expected a fast response. e-Consultations were mostly perceived as an alternative to GP appointments or calling the front desk. Patients with lower availability to the GP office had higher odds of using e-consultations as an alternative to out-of-hours service or waiting and not seeking GP care. Guidance for patient use should be developed to ensure appropriate and safe use. Further research should assess the effect of e-consultations on health outcomes and efficiency.

The Impact and Wider Implications of Remote Consultations for General Practice in Norway: Qualitative Study Among Norwegian Contract General Practitioners

BACKGROUND

The digital shift toward remote consultations in general practice needs ongoing monitoring to understand its impact on general practice organizations and the wider health care system.

OBJECTIVE

This study aimed to explore how remote consultations impact on contracted general practitioner (GP) practices and how GPs perceive the implications of this uptake for the overall health care system.

METHODS

In total, 5 focus groups were conducted with a total of 18 GPs from all 4 health regions of Norway in 2022. The material was subjected to Braun and Clarke's thematic analysis.

RESULTS

The analysis yielded six themes: (1) the design of novel effective clinical pathways: remote consultations empower GPs to tailor new effective clinical trajectories, blending modalities to address diverse needs across clinical episodes-from initial triage, through investigations to case closure; (2) increased workday flexibility: remote consultations introduce variability into daily work, allowing GPs to adjust patient contact intensity, and leading to a less stressful work-home balance; (3) erosion of organizational boundaries: easy remote access to GPs appears to reduce patients' tolerance for minor illness and self-care, hindering effective gatekeeping and shifting GPs' focus from proactive to more reactive work, increasing work-related stress; (4) degradation of clinical shrewdness: confronted with an increasing amount of unsorted and trivial remote inquiries, GPs observe challenges in detecting and prioritizing serious cases; (5) dilemmas related to responsibility, ethics, and legislation: remote consultations highlight a tension for contract GPs between legal responsibilities and ethical obligations, with implications for patients with limited health literacy; this may entail suboptimal evaluation or delayed treatment-potentially contributing to increased health care inequity; and (6) retaining clinical core values in a changing world. Overall, GPs affirm that remote consultations have come to stay and describe efforts to effectively manage the advantages and disadvantages inherent in such interactions to safeguard clinical effectiveness and organizational sustainability of primary health care.

CONCLUSIONS

The widespread adoption of remote consultations in the Norwegian contract GP scheme fundamentally reshapes the dynamics of GP work and the overall health care system. Awareness and proactive management of these changes are essential for maintaining sustainable, high-quality primary health care.

Patients' suggestions for improvements to text-based e-consultations. An online survey of users of the national health portal in Norway

Background

In recent years, text-based e-consultations have been widely implemented in general practice and are appreciated by patients for their convenience and efficiency. Policymakers aim to enhance patient access to clinical services with the general practitioner (GP) through text-based e-consultations. However, concerns are raised about their efficiency and security. We aimed to investigate users' perceptions of potential improvements in the text-based e-consultation service provided by the national health portal in Norway.

Method

We conducted an online survey among users of text-based e-consultations with the GP on the national health portal Helsenorge. The survey was available from January-February 2023 and consisted of 20 questions. This study focused on the free-text answers to the question "Do you have any suggestions to improve the service?" The framework method was used for a thematic analysis of the answers.

Results

The analysis of 2,954 free-text answers from users of the national e-consultation service resulted in six areas where suggestions for improvement were expressed. According to users, the service would benefit from: (1) a better set-up to facilitate the formulation of the patient's problem, (2) better value for money (in regards to both price and quality), (3) faster response time, (4) improved information and predictability about the status of the e-consultation (e.g., if it is received and when to expect an answer), (5) improvement in technical issues, and (6) improvement of access to dialogue-based services to replace or complement e-consultations.

Conclusion

The analysis of users' suggestions for improvements to the e-consultation service emphasised the need to customise the service to address individual patient needs. Users found a one-size-fits-all approach with mandatory questions, fixed pricing, and inflexible response times less appreciated. Some also felt forced to rely on e-consultations due to the perceived poor availability of other GP services. This highlights the importance of perceiving e-consultations not as a replacement for dialogue-enabled services, but rather as a potentially efficient addition, ensuring a well-tailored setup for appropriate patient use.

Use of Internet/Application-Based E-consults by General Practitioners in Japan to Resolve Patients' Problems: A Descriptive Observational Study

Introduction Electronic consultations (e-consults) refer to digital health technologies that enhance clinical information sharing and improve patients' access to expert healthcare providers. This study aims to describe the current utilization of the Internet/application-based e-consult system and to assess how effectively it resolves clinical questions. Methods Participants were general practitioners (GPs) who had installed the e-consult platform on their personal computers or cell phones. Hospital specialists who responded to the e-consults were previously registered on our e-consult platform and also participated in the study. We have developed and implemented an Internet/application-based e-consult system that GPs can use on their personal computers in Japan. In this descriptive study, GPs used the e-consult platform via an Internet/application to consult hospital specialists. The study period was from May 1, 2020, to October 31, 2021. The outcome measure was the resolution rate, calculated by dividing the number of cases resolved solely through e-consults by the total number of e-consult cases. Another outcome measure was the number of cases in which a plan was determined using e-consults. Other outcome measures were GP satisfaction, assessed using a 5-point Likert scale for e-consults, the number of chats required for a hospital specialist to respond, and the time from the GP's initial question to the hospital specialist's first response. Results Of the 329 e-consult cases identified, 91 conducted by GPs were included in the final analysis. The number of cases resolved using only e-consults was 47, resulting in a resolution rate of 52% in the study. The minor specialists exhibited the highest resolution rate using e-consults alone. The number of cases where a plan was determined using e-consults was 83, accounting for 91% of the total 91 cases. The level of GP satisfaction with the e-consult process was high, with a median satisfaction score of 5 on a 5-point Likert scale. Most e-consults received their initial response within two hours. The number of chats required for hospital specialists to respond was very low, with a median of only one chat being necessary. Conclusion The Internet/application-based e-consult system enabled GPs to address a wide range of medical problems. Further studies with large samples are necessary, even though these results serve as an important benchmark for future research on e-consults in Japan.

The Added Value of Using Video in Out-of-Hours Primary Care Telephone Triage Among General Practitioners: Cross-Sectional Survey Study

Background

Many countries have introduced video consultations in primary care both inside and outside of office hours. Despite some relational and technical limitations, general practitioners (GPs) have reported the benefits of video use in the daytime as it provides faster and more flexible access to health care. Studies have indicated that video may be specifically valuable in out-of-hours primary care (OOH-PC), but additional information on the added value of video use is needed.

Objective

This study aimed to investigate triage GPs' perspectives on video use in GP-led telephone triage in OOH-PC by exploring their reasons for choosing video use and its effect on triage outcome, the decision-making process, communication, and invested time.

Methods

We conducted a cross-sectional questionnaire study among GPs performing telephone triage in the OOH-PC service in the Central Denmark Region from September 5, 2022, until December 21, 2022. The questionnaire was integrated into the electronic patient registration system as a pop-up window appearing after every third video contact. This setup automatically linked background data on the contact, patient, and GP to the questionnaire data. We used descriptive analyses to describe reasons for and effects of video use and GP evaluation, stratified by patient age.

Results

A total of 2456 questionnaires were completed. The most frequent reasons for video use were to assess the severity (n=1951, 79.4%), to increase the probability of self-care (n=1279, 52.1%), and to achieve greater certainty in decision-making (n=810, 33%) (multiple answers were possible for reasons of video use). In 61.9% (n=1516) of contacts, the triage GPs anticipated that the contact would have resulted in a different triage outcome if video had not been used. Use of video resulted in a downgrading of severity level in 88.3% (n=1338) of cases. Triage GPs evaluated the use of video as positive in terms of their decision-making process (n=2358, 96%), communication (n=2214, 90.1%), and invested time (n=2391, 97.3%).

Conclusions

Triage GPs assessed that the use of video in telephone triage did affect their triage outcome, mostly by downgrading the level of care needed. The participating triage GPs found video in OOH-PC to be of added value, particularly in communication and the decision-making process.

E-participation in policy-making for health: a scoping review protocol

INTRODUCTION

For the general public, e-participation represents a potential solution to the challenges associated with in-person participation in health policy-making processes. By fostering democratic engagement, e-participation can enhance civic legitimacy and trust in public institutions. However, despite its importance, there is currently a gap in the literature regarding a comprehensive synthesis of studies on various aspects of e-participation in the health policy domain. These aspects include levels of participation, underlying mechanisms, barriers, facilitators, values and outcomes. To address this gap, our proposed scoping review aims to systematically investigate and classify the available literature related to e-participation in policy-making for health.

METHODS AND ANALYSIS

We will employ the Population, Concept and Context framework developed by Arksey and O'Malley (2005). Our population of interest will consist of participants involved in policy-making for health, including both government organisers of e-participation and participating citizens (the governed). To identify relevant studies, we will systematically search databases such as CINAHL (EBSCO), Academic Search Premier (EBSCO), Social Services Abstracts (ProQuest), Scopus (Elsevier), EMBASE (Elsevier), The Cochrane Database of Systematic Reviews, Campbell Collaboration, JBI Evidence Synthesis and PubMed using a predefined search strategy. Two independent reviewers will conduct a three-tiered screening process for identified articles, with a third reviewer resolving any discrepancies. Data extraction will follow a predefined yet flexible form. The results will be summarised in a narrative format, presented either in tabular or diagrammatic form.

ETHICS AND DISSEMINATION

The National Institute of Health Research of the Islamic Republic of Iran's ethics committee has approved this review study. Our findings will be disseminated through peer-reviewed publications, conference presentations and targeted knowledge-sharing sessions with relevant stakeholders.

Impact of COVID-19 lockdown on patient-provider electronic communications

BACKGROUND

SARS CoV-2 virus (COVID-19) impacted the practice of healthcare in the United States, with technology being used to facilitate access to care and reduce iatrogenic spread. Since then, patient message volume to primary care providers has increased. However, the volume and trend of electronic communications after lockdown remain poorly described in the literature.

METHODS

All incoming inbox items (telephone calls, refill requests, and electronic messages) sent to providers from patients amongst four primary care clinics were collected. Inbox item rates were calculated as a ratio of items per patient encountered each week. Trends in inbox rates were assessed during 12 months before and after lockdown (March 1st, 2020). Logistic regression was utilized to examine the effects of the lockdown on inbox item rate post-COVID-19 lockdown as compared to the pre-lockdown period.

RESULTS

Before COVID-19 lockdown, 2.07 new inbox items per encounter were received, which increased to 2.83 items after lockdown. However, only patient-initiated electronic messages increased after lockdown and stabilized at a rate higher than the pre-COVID-19 period (aRR 1.27, p-value < 0.001). In contrast, prescription refill requests and telephone calls quickly spiked, then returned to pre-lockdown levels.

CONCLUSION

Based on our observations, providers experienced a quick increase in all inbox items. However, only electronic messages had a sustained increase, exacerbating the workload of administrators, staff, and clinical providers. This study directly correlates healthcare technology adoption to a significant disruptive event but also shows additional challenges to the healthcare system that must be considered with these changes.

Ethical assessment of virtual consultation services: application of a practical ethical checklist to direct-to-consumer services in Aotearoa New Zealand

Introduction Evaluating digital health services from an ethical perspective remains one of the more difficult challenges in telemedicine and health technology assessment. We have previously developed a practical ethical checklist comprising 25 questions covering six ethical themes: privacy, security, and confidentiality; equity; autonomy and informed consent; quality and standards of care; patient empowerment; and continuity of care. The checklist makes ethical analysis more easily accessible to a broader audience, including health care providers, technology developers, and patients. Aim This project applies the previously developed practical ethical checklist to direct-to-consumer virtual primary care consultation services in Aotearoa New Zealand to conduct an ethical assessment. Method We first mapped the available services. The ethical framework was then applied to assess these services based on publicly available information. Results Our findings show that the examined virtual consultation services adequately address ethical considerations, particularly regarding patient data privacy and informed consent. We identified areas for improvement in equity, patient empowerment, and continuity of care. Discussion The application of this framework raises fundamental questions on how continuity of care, equity, and comprehensive care can be protected when virtual care becomes more ubiquitous. The checklist can help virtual consultation services identify areas of improvement and ensure they meet ethical criteria, thus contributing to quality of care. The framework may be adapted to other digital health services and tools, providing ethical guidance to technology developers, clinicians, and patients and their whānau (family).

Pattern of Virtual Consultations in the Kingdom of Saudi Arabia: An Epidemiological Nationwide Study

BACKGROUND

In the Kingdom of Saudi Arabia (KSA), little is known about the adoption of virtual consultations (VCs), with most studies being survey-based leading to varying results. This study aims to utilise secondary collected data on the use of both kinds of VCs currently available, and to epidemiologically describe the adoption of these consultations.

METHODS

This retrospective study analysed data provided by the Ministry of Health between January 1st 2021 and June 30th 2022. For both the home-based and the hospital-based consultations, variables included the age and sex of patients, date of consultation, duration in minutes, closure status for the appointment and the governorate in which the patient is residing. A heat map was drawn to present patterns of utilisation across the country.

RESULTS

The total number of VCs for both types were 1,008,228. For both types, females were higher adopters (54.73%). Of the total number of consultations, 751,156 were hospital-based. Of these consultations, family medicine consultations were the most common (20.42%), followed by internal medicine. Maternity follow-up clinics were higher in home-based clinics. The proportion of patient no-shows was high overall (48.30%). Utilisation was high in urban governorates, and low in rural ones.

CONCLUSION

Findings have several implications on health policy. It provides further evidence of the importance of family medicine, where it was the most common speciality even in hospital-based settings. The high variability in the adoption of consultations across rural and urban areas as well as the extremely high number of patient-no-shows warrants further investigation.

eVisits to primary care and subsequent health care contacts: a register-based study

BACKGROUND

Evidence concerning health care use related to virtual visits is conflicting. More research has been called for regarding the effectiveness of text-based virtual visits (eVisits). Therefore, we investigated patient characteristics, diagnoses, and subsequent health care contacts after eVisits to primary care.

METHODS

We conducted a register-based cohort study of eVisits to an all-virtual public primary care unit in Sweden and subsequent health care contacts within 14 days. Data for 2021 were acquired from the regional health care databases. Diagnoses were sorted into relevant diagnostic groups, such as skin diagnoses and respiratory tract diagnoses. Multiple logistic regression was performed with subsequent health care contact as the outcome variable and diagnostic group for the eVisit as the predictor variable. Analyses were adjusted for age, sex, and socioeconomic index.

RESULTS

There were 5817 eVisits to a nurse and 4267 eVisits to a general practitioner (N = 10 084). Most patients were 20 to 39 years of age (41.8%). Skin diagnoses were most frequent (47.3%), followed by respiratory tract diagnoses (19.9%). Approximately one-fourth (25.8%) of the patients who completed an eVisit with a nurse or a general practitioner had a subsequent face-to-face visit within 14 days, mostly in primary care. Subsequent contacts were more frequent after an eVisit to a nurse than to a general practitioner. After an eVisit to a general practitioner, patients with infections (especially respiratory tract but also urinary tract) and unspecified diagnoses (especially skin-related) were more likely to require further health care contact compared to a group with various other diagnoses.

CONCLUSIONS

eVisits to an all-virtual primary care unit may be appropriate for uncomplicated medical complaints. Nonetheless, the effectiveness of eVisits in terms of substitution of physical visits, and resource utilization in relation to the more complex care needs of a primary care population, should be further studied.

Patient experiences of an online consultation system: a qualitative study in English primary care post-COVID-19

BACKGROUND

Online consultation systems (OCSs) allow patients to contact their healthcare teams online. Since 2020 they have been rapidly rolled out in primary care following policy initiatives and the COVID-19 pandemic. In-depth research of patients' experiences using OCSs is lacking.

AIM

Explore patients' experiences of using an OCS.

DESIGN AND SETTING

Qualitative study in English GP practices using the Patchs OCS (www.Patchs.ai) from March 2020 to July 2022.

METHOD

Thematic analysis of 25 patient interviews and 21 467 written comments from 11 851 patients who used the OCS from nine and 240 GP practices, respectively.

RESULTS

Patients cited benefits of using the OCS as speed, flexibility, and efficiency. Nevertheless, some patients desired a return to traditional consultation methods. GP practices often did not clearly advertise the OCS or use it as patients expected, which caused frustration. Patients reported advantages of having a written record of consultations and the opportunity to communicate detailed queries in free text. Views differed on how the OCS influenced clinical safety and discussions of sensitive topics. Patients who struggled to communicate in traditional consultations often preferred using the OCS, and male patients reported being more likely to use it.

CONCLUSION

Globally, this is the largest in-depth study of patient experiences of an OCS. It contributes new knowledge that the patient experience of using OCSs can be influenced by previously unreported patient characteristics and the conditions they consult about. Further, it contributes recommendations on the design and implementation of the OCS in practice.

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study

BACKGROUND

Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics.

OBJECTIVE

We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened.

METHODS

Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis.

RESULTS

Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance.

CONCLUSIONS

Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

Translating Value Across Telehealth Stakeholders: A Rapid Review of Telehealth Measurement Evidence and a New Policy Framework to Guide Telehealth Researchers

Introduction: The surge in virtual care during the pandemic was accompanied by an increase in telehealth data of interest to policy stakeholders and other health care decision makers. However, these data often require substantial preprocessing and targeted analyses to be usable. By deliberately evaluating telehealth services with stakeholder perspectives in mind, telehealth researchers can more effectively inform clinical and policy decision making. Objective: To examine existing literature on telehealth measurement and evaluation and develop a new policy-oriented framework to guide telehealth researchers. Materials and Methods: A systematic rapid review of literature on telehealth measurement and evaluation was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The findings were analyzed and applied to the Supporting Pediatric Research on Outcomes and Utilization of Telehealth Evaluation and Measurement (STEM) Framework through the lens of key health care delivery decision makers to create a STEM Policy Framework Results: An initial search yielded 2,324 peer-reviewed articles and gray literatyre from 2012 to 2022, of which 56 met inclusion criteria. These measured and evaluated telehealth access (41.5%), quality (32.1%), cost (15.1%), experience (5.7%), and utilization (5.7%), consistent with the STEM Framework domains, but there was no universal approach. The STEM Policy Framework focuses this literature by describing data measures for each domain from the perspectives of five stakeholders. Conclusions: Literature describing measurement and evaluation approaches for telehealth is limited and not standardized, with few considering policy stakeholder perspectives. With this proposed STEM Policy Framework, we aim to improve this body of literature and support researchers seeking to inform telehealth policy through their work.

Successful Electronic Consultation Service Initiative in Quebec, Canada With Primary Care Physicians' and Specialists' Experiences on Acceptance and Use of Technological Innovation: Cross-Sectional Exploratory Study

BACKGROUND

Electronic consultation (eConsult) is an eHealth service that allows primary care providers (PCPs) to electronically consult specialists regarding their patients' medical issues. Many studies have demonstrated that eConsult services improve timely access to specialist care; prevent unnecessary referrals; improve PCPs', specialists', and patients' satisfaction; and therefore have a large impact on costs. However, no studies have evaluated PCPs' and specialists' acceptance of eConsult services in Quebec, Canada, and worldwide.

OBJECTIVE

This exploratory study aims to identify factors affecting eConsult service acceptance by PCPs and specialists in urban and rural primary care clinics across 3 regions in the province of Quebec, Canada, by integrating the Unified Theory of Acceptance and Use of Technology and Task-Technology Fit (TTF) models and user satisfaction. This research was designed to broaden and assist in scaling up this effective eHealth service innovation across the province.

METHODS

A cross-sectional web-based survey was sent to all PCPs (n=263) and specialists (n=62) who used the eConsult Quebec Service between July 2017 and May 2021. We proposed a unified model integrating the Unified Theory of Acceptance and Use of Technology model and TTF model and user satisfaction by endorsing 11 hypotheses. The partial least squares was used to investigate factors influencing the acceptance of the eConsult Quebec Service.

RESULTS

Of the 325 end users, 136 (41.8%) users responded (PCPs: 101/263, 38.4%; specialists: 35/62, 57%). The results of the analysis with partial least squares method indicate that 9 of our 11 hypotheses are supported. The direct relationships uniting the various constructs of the model highlighted the importance of several key constructs and predominant correlations. The results suggest that satisfaction is the key driver behind the use of the eConsult Quebec Service. Performance expectancy (P<.001) and effort expectancy (P=.03) can have a positive impact on behavioral intention (BI), and BI (P<.001) can impact adoption. TTF has an influence on performance expectancy (P<.001), adoption (P=.02), and satisfaction (P<.001). However, the results show that there is no direct effect between social influence (P=.38) and BI or between facilitating conditions (P=.17) and adoption.

CONCLUSIONS

This study provides a better understanding of the factors influencing PCPs' and specialists' intention to adopt the eConsult Quebec Service. Furthermore, this study tests a research model and a technology that have never been explored in Quebec until now. On the basis of the results, the service is a good fit to meet the users' need to improve access to specialized medical advice. Therefore, the results of our study have made a valuable contribution to the implementation of the service by policy makers in order to maximize acceptance, use, adoption, and success across the province of Quebec. Moreover, after 4 successful years, the eConsult Quebec pilot project is now the Conseil Numérique digital consultation service.

A Phenomenological Inquiry of the Shift to Virtual Care Delivery: Insights from Front-Line Primary Care Providers

The rapid deployment of virtual primary care visits served as a first-line response to COVID-19 and can now be examined for insights, particularly as virtual care is playing an ongoing role in patient care and consultations. Input from primary care providers directly responsible for virtual care delivery is needed to inform policies and strategies for quality care and interactions. The overarching goal of this research study was to examine the use of virtual care as a mechanism for primary healthcare delivery. A phenomenological approach investigated the shift in primary care service delivery as experienced by primary care providers and initiated during the COVID-19 pandemic. Focus groups were conducted with primary care providers (n = 21) recruited through email, advertisements, and professional organizations, exploring how virtual care was delivered, the benefits and challenges, workflow considerations, and recommendations for future use. Integrating virtual care was performed with a great deal of autonomy as well as responsibility, and overwhelmingly depended on the telephone. Technology, communication, and workflow flexibility are three key operational aspects of virtual care and its delivery. Providers highlighted cross-cutting themes related to the dynamics of virtual care including balancing risk for quality care, physician work/life balance, efficiency, and patient benefits. Primary care providers felt that virtual care options allowed increased flexibility to attend to the needs of patients and manage their practice workload, and a few scenarios were shared for when virtual care might be best suited. However, they also recognized the need to balance in-person and virtual visits, which may require guidelines that support navigating various levels of care. Overall, virtual care was considered a good addition to the whole 'care package' but continued development and refinement is an expectation for optimizing and sustaining future use.

Implementation of Video-Based Care in Interdisciplinary Primary Care Settings at the Veterans Health Administration: Qualitative Study

BACKGROUND

With the rapid shift to telehealth, there remains a knowledge gap in how video-based care is implemented in interdisciplinary primary care (PC) settings.

OBJECTIVE

The objective of this study was to gain an in-depth understanding of how video telehealth services were implemented in PC from the perspectives of patients and interdisciplinary PC team members at the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic.

METHODS

We applied a positive and negative deviance approach and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. A total of 12 VHA sites were included in the study, where 43 PC interdisciplinary team members (August-October 2022) and 25 patients (February-May 2023) were interviewed. The 5 domains from the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework guided the development of the 2 study interview guides (provider and patient). We identified themes that emerged across all interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis of the interview transcripts. The analysis was guided by 5 a priori NASSS domains: (1) patient condition or characteristic, (2) technology, (3) adopter system, (4) health care organization, and (5) adaptation over time.

RESULTS

The study findings include the following common themes and factors, organized by the 5 NASSS domains: (1) patient condition or characteristic-visit type or purpose (eg, follow-up visits that do not require physical examination), health condition (eg, homebound or semihomebound patients), and sociodemographic characteristic (eg, patients who have a long commute time); (2) technology-key features (eg, access to video-enabled devices), knowledge (eg, how to use videoconferencing software), and technical support for patients and providers; (3) adopter system-changes in staff roles and clinical practice (eg, coordination of video-based care), provider and patient preference or comfort to use video-based care, and caregiver's role (eg, participation of caregivers during video visits); (4) health care organization-leadership support and access to resources, scheduling for video visits (eg, schedule or block off digital half or full days), and training and telehealth champions (eg, hands-on or on-site training for staff, patients, or caregivers); (5) adaptation over time-capacity to improve all aspects of video-based care and provide continued access to resources (eg, effective communication about updates).

CONCLUSIONS

This study identified key factors associated with the implementation of video-based services in interdisciplinary PC settings at the VHA from the perspectives of PC team members and patients. The identified multifaceted factors may inform recommendations on how to sustain and improve the provision of video-based care in VHA PC settings as well as non-VHA patient-centered medical homes.

Use of Video in Telephone Triage in Out-of-Hours Primary Care: Register-Based Study

Background

Out-of-hours primary care (OOH-PC) is challenging due to high workloads, workforce shortages, and long waiting and transportation times for patients. Use of video enables triage professionals to visually assess patients, potentially ending more contacts in a telephone triage contact instead of referring patients to more resource-demanding clinic consultations or home visits. Thus, video use may help reduce use of health care resources in OOH-PC.

Objective

This study aimed to investigate video use in telephone triage contacts to OOH-PC in Denmark by studying rate of use and potential associations between video use and patient- and contact-related characteristics and between video use and triage outcomes and follow-up contacts. We hypothesized that video use could serve to reduce use of health care resources in OOH-PC.

Methods

This register-based study included all telephone triage contacts to OOH-PC in 4 of the 5 Danish regions from March 15, 2020, to December 1, 2021. We linked data from the OOH-PC electronic registration systems to national registers and identified telephone triage contacts with video use (video contact) and without video use (telephone contact). Calculating crude incidence rate ratios and adjusted incidence rate ratios (aIRRs), we investigated the association between patient- and contact-related characteristics and video contacts and measured the frequency of different triage outcomes and follow-up contacts after video contact compared to telephone contact.

Results

Of 2,900,566 identified telephone triage contacts to OOH-PC, 9.5% (n=275,203) were conducted as video contacts. The frequency of video contact was unevenly distributed across patient- and contact-related characteristics; it was used more often for employed young patients without comorbidities who contacted OOH-PC more than 4 hours before the opening hours of daytime general practice. Compared to telephone contacts, notably more video contacts ended with advice and self-care (aIRR 1.21, 95% CI 1.21-1.21) and no follow-up contact (aIRR 1.08, 95% CI 1.08-1.09).

Conclusions

This study supports our hypothesis that video contacts could reduce use of health care resources in OOH-PC. Video use lowered the frequency of referrals to a clinic consultation or a home visit and also lowered the frequency of follow-up contacts. However, the results could be biased due to confounding by indication, reflecting that triage GPs use video for a specific set of reasons for encounters.

A Bibliometric Review of Constituents, Themes, and Trends in Online Medical Consultation Research

As an emerging form of health care with accelerated growth in recent years, online medical consultation (OMC) has received extensive attention worldwide. Although the number of studies on OMC has increased substantially, few provide a comprehensive and up-to-date review of OMC's research constituents, themes, and trends. This study, therefore, extracted 1,801 OMC-related articles published in English from the Web of Science (WoS) Core Collection database during the past 30 years and employed a bibliometric analysis of WoS and CiteSpace to examine major constituents' distribution, collaboration relationships, themes, and trends. The results indicate that the United States, England, and China contributed the most to the proliferation of OMC studies. The United States had the greatest academic influence and the most collaborative connections, while China demonstrated the sharpest increase and most active development in recent years. However, there is a lack of substantial and close collaboration between researchers worldwide. The main themes of OMC research were Internet hospitals, COVID-19, mixed methods, online health community, and information technology. Researchers have recently shifted their attention to social media, management, efficacy, word of mouth, mental health, and anxiety. This review paper provides researchers and practitioners with a holistic and clear understanding of the features and trends of OMC research. It also identifies potential areas for future OMC research and sheds light on OMC practices.

Effectiveness and safety of asynchronous telemedicine consultations in general practice: a systematic review

BACKGROUND

There is a focus on increasing asynchronous telemedicine use, which allows medical data to be transmitted, stored, and interpreted later; however, limited evidence of the quality of care it allows in general practice hinders its use.

AIM

To investigate uses and effectiveness of asynchronous telemedicine in general practice, according to the domains of healthcare quality, and describe how the COVID-19 pandemic changed its use.

DESIGN & SETTING

Systematic review in general practice.

METHOD

A systematic search was carried out across four databases using terms related to general practice, asynchronous telemedicine, uses, and effectiveness, and supported by citation searching. This was followed by screening according to pre-defined criteria, data extraction, and critical appraisal. Narrative synthesis was then undertaken guided by the six domains of healthcare quality and exploring differences in use before and following the COVID-19 pandemic.

RESULTS

Searches yielded 6864 reports; 27 reports from 23 studies were included. Asynchronous telemedicine is used by a range of staff and patients across many countries. Safety and equity are poorly reported but there were no major safety concerns. Evidence from other domains of healthcare quality show effectiveness in making diagnoses, prescribing medications, replacing other consultations, providing timely care, and increased convenience for patients. Efficiency is impacted by negative effects on workflow, through poor implementation and patient non-adherence, limiting usability and requiring new administrative approaches from healthcare staff. Asynchronous telemedicine use increased rapidly from March 2020, following the COVID-19 pandemic outbreak.

CONCLUSION

Asynchronous telemedicine provides quality care for patients but is limited by reports of increased workload and inefficient workflow compared with face-to-face consultations. Limits of evidence include heterogeneity and small-scale studies. Further research into cost-effectiveness, equity, safety, and sustained implementation will influence future policy and practice.

Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adults

BACKGROUND

Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread. With remote consultations likely to continue in UK primary care, it is important to understand people's perceptions of remote consultations and identify potential resulting inequalities.

AIM

To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels.

DESIGN AND SETTING

A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic.

METHOD

In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021). Items included satisfaction with remote consultations and demographic variables. Associations were analysed using multivariable regression.

RESULTS

A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties. Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = -0.82, 95% confidence interval [CI] = -1.41 to -0.23) or those with low or no qualifications (B = -1.65, 95% CI = -2.29 to -1.02). People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = -1.94, 95% CI = -3.11 to -0.78), although caution is warranted due to small group numbers.

CONCLUSION

These findings can inform the use and adaptation of remote consultations in primary care. Adults with lower educational levels may need additional support to improve their experience and ensure equitable care via remote consultations.

What are the determinants of older people adopting communicative e-health services: a meta-ethnography

BACKGROUND

Gradually, society has shifted more services online, with COVID-19 highlighting digital inequalities in access to services such as healthcare. Older adults can experience such digital inequalities, yet this group is also more likely to need medical appointments, compared to younger people. With the growing digitalisation of healthcare, it is increasingly important to understand how older people can best use communicative e-health services to interact with healthcare services. This is especially if older adults are to access, and actively interact with health professionals/clinicians due to their general health decline. This review aims to synthesise older adults' experiences and perceptions of communicative e-health services and, in turn, identify barriers and facilitators to using communicative e-health services.

METHODS

A meta-ethnography was conducted to qualitatively synthesise literature on older adults' experiences of using communicative e-health services. A systematic search, with terms relating to 'older adults', 'e-health', 'technology', and 'communication', was conducted on six international databases between January 2014 and May 2022. The search yielded a total of 10 empirical studies for synthesis.

RESULTS

The synthesis resulted in 10 themes that may impact older adults' perceptions and/or experiences of using communicative e-health services. These were: 1) health barriers, 2) support networks, 3) application interface/design, 4) digital literacy, 5) lack of awareness, 6) online security, 7) access to digital devices and the internet, 8) relationship with healthcare provider(s), 9) in-person preference and 10) convenience. These themes interlink with each other.

CONCLUSION

The findings suggest older adults' experiences and perceptions of communicative e-health services are generally negative, with many reporting various barriers to engaging with online services. However, many of these negative experiences are related to limited support networks and low digital literacy, along with complicated application interfaces. This supports previous literature identifying barriers and facilitators in which older adults experience general technology adoption and suggests a greater emphasis is needed on providing support networks to increase the adoption and usage of communicative e-health services.

Empirical Evidence of Internal and External Factors Influencing Users' Motivation Toward Teleconsultation Use

Introduction: The use of teleconsultation systems has increased in recent years, which has improved patients' access to health care providers and enabled seamless interaction between them. The literature points out several factors that either facilitate or impede the use of teleconsultation. However, there is a lack of studies that provide empirical evidence of factors that influence consumers' motivation toward the use of teleconsultation systems. Aim and Objective: This study aimed to provide empirical evidence of the internal and external factors that influence consumers' motivation toward the use of teleconsultation systems. Methods: A cross-sectional survey was used to collect data from consumers who used a real-time teleconsultation system called the Sehha application in Saudi Arabia between March 13 and June 14, 2021. SPSS 27.0.1 was used for descriptive analysis. Results: Four hundred eighty-five participants completed the survey, 471 of whom were included in the analysis. The findings confirmed that internal and external factors exert an influence on consumers' motivation toward the use of teleconsultation systems. The findings indicated that the presence of factors such as saving time, saving cost, accessibility to health care, ease-of-use, reliable internet access, availability of devices, and appropriate places during the online connection would increase consumers' motivation toward teleconsultation systems use. Also, the findings indicated that users' familiarity with systems similar to teleconsultation systems, users' perception of teleconsultation convenience, the influence of others on users' decision to use teleconsultation, and user's skills and confidence in using teleconsultation easily, and their trust in the teleconsultation system would also increase their motivation to use it. Furthermore, the findings showed that demographic factors, including age, gender, level of education, and employment status, did not influence users' motivation toward the use of teleconsultation Conclusions: This study provided empirical evidence of a variety of internal and external factors that exert an influence on consumers' motivation toward the use of teleconsultation systems.

Exploring the use, usefulness and ease of use of digital occupational health services: A descriptive correlational study of customer experiences

Objective

This study examined the customer experiences of use, perceived usefulness and ease of use of digital occupational health (OH) services.

Methods

A cross-sectional study based on an electronic survey was conducted between December 2022 and January 2023. A total of 9871 OH customers responded to the survey. The sample was restricted to respondents who used digital OH services (n = 7275). An analysis of variance was run to test the relationships between respondents' characteristics and the rate of usefulness, and ease of use variables.

Results

The most commonly used digital services were appointment booking, access to health information recorded by professionals and prescription renewal, and the digital services provided by physicians and nurses. Respondents expressed quite high satisfaction with the digital services, but not as much with their usefulness and ease of use. Females, individuals under 50 years of age, those with higher education, working in white-collar or managerial positions and possessing proficient information and communication technology (ICT) skills gave the most positive evaluations regarding usefulness and ease of use.

Conclusions

There was a certain level of mixed experiences among respondents regarding the usefulness and ease of use of digital OH services. We can also conclude that individuals who possess the necessary ICT skills can more easily take full advantage of the available digital services. When customers are proficient in using digital services, they can confidently interact with professionals. Regardless of the user's age, gender, education or profession, it is crucial for service providers always to strive to improve the usability of digital services.

A proposed methodology for conducting a remote rigid gas permeable contact lens consultation

PURPOSE

COVID-19 spread to numerous countries, overwhelming healthcare systems and economies worldwide. COVID-19 restrictions have prevented patients from attending consultations in person and led to the further development of telemedicine to provide health care. The situation also applies to contact lens (CL) practitioners and their patients; telemedicine enables practitioners to provide patients with regular and continuing care. This study aimed to investigate available tools to enable continuing care for rigid gas permeable (RGP) CL wearers who are unable to attend face-to-face consultations.

METHODS

The study consists of three components. Firstly, an approach to enable the assessment of a patient's CL fitting and cornea remotely. Secondly, to find an affordable and reliable method to obtain a patient's visual acuity (VA), and thirdly, to develop a questionnaire to provide practitioners with information to deliver optimal patient care.

RESULTS

The use of a macro lens, smartphone, and auxiliary materials enables high-quality images of the anterior eye and RGP CL to be obtained. Two free and validated smartphone applications (apps) for VA measurements were identified which are available on Android and iOS systems. Two questionnaires were also developed to enable practitioners to obtain additional patient information to facilitate optimal patient care.

CONCLUSION

This study has developed the components of a remote CL consultation to enable patients who cannot attend scheduled appointments to receive care and advice to ensure the safety of their RGP CL wear. The tools involved in this study are low-cost, affordable, and an adjunct, not a substitute, for face-to-face consultations.

The Impact of Virtual Consultations on the Quality of Primary Care: Systematic Review

BACKGROUND

The adoption of virtual consultations, catalyzed by the COVID-19 pandemic, has transformed the delivery of primary care services. Owing to their rapid global proliferation, there is a need to comprehensively evaluate the impact of virtual consultations on all aspects of care quality.

OBJECTIVE

This study aims to evaluate the impact of virtual consultations on the quality of primary care.

METHODS

A total of 6 databases were searched. Studies that evaluated the impact of virtual consultations, for any disease, were included. Title and abstract screening and full-text screening were performed by 2 pairs of investigators. Risk of bias was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis of the results was performed.

RESULTS

In total, 30 studies (5,469,333 participants) were included in this review. Our findings suggest that virtual consultations are equally effective to or more effective than face-to-face care for the management of certain conditions, including mental illness, excessive smoking, and alcohol consumption. Overall, 4 studies indicated positive impacts on some aspects of patient-centeredness; however, a negative impact was noted on patients' perceived autonomy support (ie, the degree to which people perceive those in positions of authority to be autonomy supportive). Virtual consultations may reduce waiting times, lower patient costs, and reduce rates of follow-up in secondary and tertiary care settings. Evidence for the impact on clinical safety is extremely limited. Evidence regarding equity was considerably mixed. Overall, it appears that virtual care is more likely to be used by younger, female patients, with disparities among other subgroups depending on contextual factors.

CONCLUSIONS

Our systematic review demonstrated that virtual consultations may be as effective as face-to-face care and have a potentially positive impact on the efficiency and timeliness of care; however, there is a considerable lack of evidence on the impacts on patient safety, equity, and patient-centeredness, highlighting areas where future research efforts should be devoted. Capitalizing on real-world data, as well as clinical trials, is crucial to ensure that the use of virtual consultations is tailored according to patient needs and is inclusive of the intended end users. Data collection methods that are bespoke to the primary care context and account for patient characteristics are necessary to generate a stronger evidence base to inform future virtual care policies.

Perspectives of patients with colorectal cancer liver metastases on e-consultation in transmural care: a qualitative study : Is privacy really an issue?

BACKGROUND

Comprehensive cancer networks have been established to deliver high-quality care for patients with cancer. Logistic challenges are faced, when patients need to be referred for specialized treatments. Despite strengthened privacy legislations, digital platforms are increasingly used to consult specialists from dedicated liver centers or refer patients with colorectal cancer liver metastases (CRLM) for local treatment strategies. This qualitative study aimed to explore the perspectives of patients with CRLM regarding e-consultation of transmural specialists.

METHODS

A focus group study was conducted. Patients referred from regional hospitals to an academic liver center for treatment of CRLM were asked to participate. Focus group discussions were audio-recorded and transcribed verbatim. A thematic content analysis of data was conducted, comprising open, axial, and selective coding of the transcripts. The consolidated criteria for reporting qualitative research (COREQ) were used.

RESULTS

Two focus groups were held, involving 11 patients and 8 relatives. Three major themes were identified with regard to e-consultation in transmural care: 'data management', 'expertise', and 'information and coordination'. Confidence in the expertise of physicians appeared most important during the course of treatment, as patients experienced uncertainty after diagnosis of cancer. Despite the privacy risks, use of digital communication platforms to contact experts in the field were strongly endorsed to improve eligibility for potentially curative treatment. Moreover, e-consultation of specialists may reduce waiting times, due to effective coordination of care.

CONCLUSION

Initiatives to improve medical data transfer between care providers were encouraged to achieve effective coordination of oncological care. The potential hazard of privacy violation associated with digital data exchange is accepted by patients and their relatives, provided that use of digital data improves patient's own health care, research or education.

Workload effects of online consultation implementation from a Job-Characteristics Model perspective: a qualitative study

BACKGROUND

Online consultation (OC) was previously promoted by the NHS to solve primary care workload challenges. Its implementation was sped up during the COVID-19 pandemic. Workload effects are widely debated. Using a job design perspective may enhance understandings of workload effect.

AIM

To qualitatively interrogate the workload experiences of primary care staff involved in OC implementation, using the Job Characteristics Model (JCM) to enable the following: a clearer understanding of the primary care staff psychological experiences; and recommendations informing the design of digital implementations and continued use.

DESIGN & SETTING

A qualitative interview study of GP practices using OC within South West England.

METHOD

Thirteen participants representing seven practices completed JCM-based semi-structured telephone interviews. An abductive theoretically driven thematic analysis was completed.

RESULTS

Participants experienced different tasks pre- and post-implementation of OC, and adapted differently to them. Differences included the following: contact modality change, some administrative staff felt removed from patient contact; and in perceived autonomy, some GPs valued increased workload control. Variation in workload experience was affected by job role and practice context, and the form of and rationale for implementation. Use of a psychological model (the JCM) allowed clearer consideration of the effects of change, as well as OC on workload.

CONCLUSION

Psychological theory may be helpful in interpreting workload effects of technology implementation such as OC. Designing change to include consideration of technology effects, psychological experiences, differences across roles, and individual and practice contexts may be important for technology implementation and evaluation of its workload effects.

Older patients' experiences of access to and use of e-consultations with the general practitioner in Norway: an interview study

OBJECTIVE

To explore older patients' experiences with accessing and using e-consultations to send text-based clinical inquiries to the general practitioner (GP) online.

DESIGN

Qualitative study based on semi-structured interviews. Results were analysed through a six-phase thematic analysis and interpreted through Levesque's framework of patient-centred access to health care.

SETTING

General practice in Norway.

SUBJECTS

Patients aged over 65 years (n = 16) with experience in using e-consultations.

RESULTS

Respondents considered e-consultations as an integrated part of general practice which helped them achieve better access to health care. We identified four themes describing older patients' access to and use of e-consultations: 1) the importance of digital health literacy to learn about and use the service - and the fear of losing it, 2) the high availability of the service as the main advantage, due to the perceived unavailability of physical GP services, 3) the importance of voluntary use of e-consultations, 4) the importance of a trusting relationship with the GP.

IMPLICATIONS

Information about e-consultations and guidelines for suitable use are recommended to ensure equal access to all patients, regardless of their digital health literacy. Availability problems and high work burdens for the GPs could affect the patients' choice for using e-consultations. If e-consultations are used for triage purposes, caution should be taken to avoid a shift in workload from the health secretary to the GP.Key points of articleThe extended use of e-consultations with the general practitioner has raised concerns that the service may not be accessible and suitable for older patients.For older users, e-consultations can represent a positive addition to physical consultation forms due to the high availability of the service in a general practice setting characterised by long waiting times.Digital health literacy is essential to learn about and use the service. Information about the service and how to use it should be available to all patients to ensure equal access.A trusting relationship with the GP is described as essential for older patients to perceive the outcome of e-consultations as appropriate and safe.

Exploring the rise of telehealth services in Malaysia: A retrospective study

Background

Telehealth services have gained popularity in Malaysia, providing convenient consultations during the COVID-19 pandemic. However, there is limited research on their usage, user demographics and prescribed medications. This study aims to fill that gap by investigating telehealth service utilisation in community pharmacies and identifying trends in common diagnoses and medications prescribed.

Methods

A retrospective observational study was conducted using a telehealth services database in Malaysian community pharmacies. Consultation records from January 2019 to December 2021 were extracted using a data collection form. The study identified the service usage over time, demographic profiles of users and the most common diagnoses and prescribed medications. Diagnoses were classified using the International Classification of Disease, 10th Revision (ICD-10), and medications were classified using the Anatomical Therapeutic Chemical (ATC) system.

Results

The study included 835,826 telehealth service records, with 88.8% being assisted consultations with e-prescriptions and 11.2% direct consultations. The user population consisted of primarily Malaysians (96.9%), with a mean age of 50 ± 21 years. Both telehealth services saw an increase in unique users over the 3-year study period. There was a moderate correlation between active COVID-19 cases and monthly user count. Assisted consultations were more widely used than direct consultations.

Conclusion

This study found an increased usage of telehealth services and its potential to remain as a healthcare system feature in community pharmacies. Further investigation into the impact on medication safety, quality and healthcare delivery is warranted.

Characterizing the use of virtual care in primary care settings during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

In March 2020, Canada implemented restrictions to curb viral transmission of COVID-19, which resulted in abrupt disruptions to conventional (in-person) clinical care. To retain continuity of care the delivery of primary care services shifted to virtual care. This study examined the nature of virtual visits, characterizing the use and users of virtual care in primary care settings from March 14/20 to June 30/20 of the COVID-19 pandemic.  METHODS: Retrospective cohort study of primary care providers in Manitoba, Canada that participate in the Manitoba Primary Care Research Network (MaPCReN) and offered ≥ 1 virtual care visit between 03/14/20 and 06/30/20 representing 142,616 patients. Tariff codes from billing records determined the visit type (clinic visit, virtual care). Between 03/14/20, and 06/30/20, we assessed each visit for a follow-up visit between the same patient and provider for the same diagnosis code. Patient (sex, age, comorbidities, visit frequency, prescriptions) and provider (sex, age, clinic location, provider type, remuneration, country of graduation, return visit rate) characteristics describe the study population by visit type. Generalized estimating equation models describe factors associated with virtual care.  RESULTS: There were 146,372 visits provided by 154 primary care providers between 03/14/20 and 06/30/20, of which 33.6% were virtual care. Female patients (OR 1.16, CI 1.09-1.22), patients with ≥ 3 comorbidities (OR 1.71, CI 1.44-2.02), and patients with ≥ 10 prescriptions (OR 2.71, 2.2-1.53) had higher odds of receiving at least one virtual care visit compared to male patients, patients with no comorbidities and patients with no prescriptions. There was no significant difference between the number of follow-up visits that were provided as a clinic visit compared to a virtual care visit (8.7% vs. 5.8%) (p = 0.6496).

CONCLUSION

Early in the pandemic restrictions, approximately one-third of visits were virtual. Virtual care was utilized by patients with more comorbidities and prescriptions, suggesting that patients with chronic disease requiring ongoing care utilized virtual care. Virtual care as a primary care visit type continues to evolve. Ongoing provision of virtual care can enhance quality, patient-centered care moving forward.

Remote consultations in primary care across low-, middle- and high-income countries: Implications for policy and care delivery

The COVID-19 pandemic mandated a substantial switch in primary health care delivery from an in-person to a mainly remote telephone or video service. As the COVID-19 pandemic approaches its third year, limited progress appears to have been made in terms of policy development around consultation methods for the post-acute phase of the pandemic. In September 2020, the International Primary Care Respiratory Group convened a global panel of primary care clinicians - including family physicians, paediatricians, pharmacists, academics and patients - to consider the policy and health management implications of the move to remote consultations in the primary care setting. The group gave special consideration to how and how far remote consultations should be integrated into routine primary health care delivery. Remote consultations can be a useful alternative to in-person consultations in primary care not only in situations where there is a need for viral infection control but also for the routine delivery of chronic disease management. However, they may not be more time efficient for the clinician, and they can add to the workload and work-related stress for primary care practitioners if they remain the dominant consultation mode. Remote consultations are also less appropriate than in-person consultations for new disease diagnosis, dealing with multiple issues and providing complex care. Ensuring health care professionals have the appropriate skill set to effectively deliver remote consultations, administrative and/or IT support and appropriate reimbursement will be key to achieving optimal integration of remote consultations into routine clinical practice. Addressing digital access and digital literacy issues at a societal level will also be essential to ensure individuals have fair and equitable access to the internet and sufficient security for exchange of personal and health-related data.

Specialized healthcare practitioners' challenges in performing video consultations to patients in Nordic Countries - a systematic review and narrative synthesis

BACKGROUND

Video consultations are becoming an important telemedicine service in Nordic countries. Its use in specialized healthcare increased significantly during COVID-19 pandemic. Despite advantages video consultations have, it may also produce challenges for practitioners. Identifying and understanding these challenges may contribute to how managers can support these practitioners and thereby improve work related wellbeing and quality of care.

METHODS

We designed this study as systematic review of the literature with narrative synthesis and conducted a thematic analysis. We conducted review about the use of video consultations in specialized healthcare in Nordic countries to identify and categorize challenges experienced and/or perceived by practitioners. We searched Ovid MEDLINE(R), EMBASE, APA PsycINFO, and CINAH, from 2011 to 2021. Eligibility criteria were population - practitioners in specialized healthcare with experience in video consultations to patients, interest - challenges experienced and/or perceived by practitioners and, context - outpatient clinics in Nordic countries.

RESULTS

We included four qualitative and one mixed method studies, published between 2018 and 2021 in Norway, Denmark, and Sweden. By thematic analysis we identified three main themes: challenges related to video consultation, challenges related to practitioner and, challenges related to patient. These themes are composed of 8 categories: technology uncertainties, environment and surroundings, preparation for requirements, clinical judgment, time management, practitioners' idiosyncrasies, patients' idiosyncrasies and patients' suitability and appropriateness. Challenges from technology uncertainties category were most frequent (dominant) across all clinical specializations.

CONCLUSION

Findings indicate the scarcity of the research and provide rationale for further research addressing challenges in providing video consultations in the Nordic context. We suggest updating this review when the amount of available research increases.

The Current Status of Telemedicine Technology Use Across the World Health Organization European Region: An Overview of Systematic Reviews

BACKGROUND

Several systematic reviews evaluating the use of telemedicine by clinicians, patients, and health authorities to improve the delivery of care in the 53 member states of the World Health Organization (WHO) European Region have been conducted in recent years. However, a study summarizing the findings of these reviews has not been conducted.

OBJECTIVE

This overview of systematic reviews aimed to summarize findings regarding the use of telemedicine across the 53 member states and identify the medical fields and levels of care in and at which the effectiveness, feasibility, and applicability of telemedicine have been demonstrated. The barriers to and facilitators of telemedicine use were also evaluated and collated to help with the design and implementation of telemedicine interventions.

METHODS

Through a comprehensive systematic evaluation of the published and unpublished literature, we extracted clinical, epidemiological, and technology-related data from each review included in the study. We focused on evaluating the barriers to and facilitators of the use of telemedicine apps across the 53 member states considered. We rated the methodological quality of each of the included reviews based on A Measurement Tool to Assess Systematic Review 2 approach and judged the overall certainty of evidence by using the Grading of Recommendations, Assessment, Development, and Evaluations methodology. The entire process was performed by 2 independent authors.

RESULTS

This overview drew on data from >2239 primary studies, with >20,000 enrolled patients in total, within the WHO European Region. On the basis of data from randomized trials, observational studies, and economic evaluations from several countries, the results show a clear benefit of telemedicine technologies in the screening, diagnosis, management, treatment, and long-term follow-up of a series of chronic diseases. However, we were unable to pool the results into a reliable numeric parameter because of the high heterogeneity of intervention methodologies, scheduling, primary study design discrepancies, settings, and geographical locations. In addition to the clinical outcomes of the interventions, the social and economic outcomes are highlighted.

CONCLUSIONS

The application of telemedicine is well established across countries in the WHO European Region; however, some countries could still benefit from the many uses of these digital solutions. Barriers related to users, technology, and infrastructure were the largest. Conversely, the provision of health services using technological devices was found to significantly enhance patients' clinical outcomes, improve the long-term follow-up of patients by medical professionals, and offer logistical benefits for both patients and health workers.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42022309375; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=309375.

Exploring Adult Patients’ Perceptions and Experiences of Telemedicine Consultations in Primary Care: A Qualitative Systematic Review

The COVID-19 pandemic transformed a gradual uptake of telemedicine, into a sudden worldwide implementation of telemedicine consultations. Primary care is a particular area affected and one where telemedicine consultations are expected to be the future. However, for effective long-term implementation it is vital that patient perceptions and experiences are understood. The aim of this qualitative systematic review was to explore the perceptions and experiences of adults who have used telemedicine consultations in primary care. Studies were identified through a search of four electronic databases (MEDLINE, EMBASE, CINAHL, and CENTRAL) alongside reference list and citation searches. Quality assessment was conducted using the CASP checklist and data was synthesized using a simplified approach to thematic analysis. From 2492 identified records, ten studies met the eligibility criteria all of which were judged as either good or moderate quality. Three themes were identified which were potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations in primary care. Within these themes, sixteen sub-themes were identified with examples including accessibility and convenience for potential benefits, lack of face-to-face interaction and impersonal consultations for potential barriers, and continuity of care for beneficial prerequisites. Analysing these subthemes, four main recommendations for practice can be made which are to utilise continuity of care, offer both video and telephone consultations, provide adequate support, and that healthcare professionals should demonstrate an explicit understanding of the patient’s health issues. Further research is needed to explore and expand on this topic area and future research should be viewed as a continuous process.

Examining virtual visit use during a pandemic and perspectives of primary care providers, patients and caregivers: a mixed-methods research protocol

Introduction

COVID-19 prompted rapid shifts to virtual primary care; however, the secondary implications and ideal applications of this change require further consideration. Patient and public stakeholder input has been bypassed. To integrate virtual care (VC) in what currently appears to be a lengthier battle against COVID-19 and related sequelae, further investigation is needed to support ideal implementation and use. This study aims to describe factors associated with the use of virtual visits in primary care practices, along with more in-depth description of users’ experiences and perspectives.

Methods and analysis

This study will be conducted in three phases, using a mixed-methods approach and in consultation with community advisors. Phase 1 will analyse data from electronic medical records (EMRs) to characterise the use and users of VC in primary care during the early phase of the COVID-19 pandemic. Analysis will be primarily descriptive; regression modelling will assess associations between patient and provider factors with a virtual visit. In phase 2, we will use an EMR-facilitated process to automate the distribution of patient surveys within an estimated 10 clinics. These surveys aim to describe care experiences, transactional use and perspectives of VC. In phase 3, focus groups with patients, caregivers and primary care clinicians will seek more in-depth exploration of VC regarding accessibility of care, acceptability and perceptions of quality care. Interpretive phenomenological analysis will be used for thematic analysis. The framework method will employ a matrix structure to organise the data and to facilitate comparison, integration and further interpretation.

Ethics and dissemination

This study has been approved by the University of Manitoba’s Health Research Ethics Board (HS24197). A co-designed dissemination strategy will include reports and infographics to policymakers and the public, manuscripts and presentations to academic and clinician audiences, and contributions to a learning plan for professional development.

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.

Online health management continuance and the moderating effect of service type and age difference: A meta-analysis

Numerous empirical studies have been carried out to explore factors of online health management continuance. However, results were not unified. We thus conducted a meta-analysis to identify influential factors and potential moderators. A systematic literature search was performed in nine databases (PubMed, Web of Science, the Cochrane Library, Ovid of JBI, CINAHL, Embase, CNKI, VIP, and CBM) published up to December 2020 in the English or Chinese language. Meta-analysis of combined effect size, heterogeneity, moderator analysis, publication bias assessment, and inter-rater reliability was conducted. Totally 41 studies and 12 pairwise relationships were identified. Confirmation, perceived usefulness, satisfaction, information quality, service quality, perceived ease of use, and trust were all critical predictors. Service type and age difference showed their moderating effects respectively. The perceived usefulness was more noteworthy in medical service than health and fitness service. The trust was more noteworthy in young adults. The results confirmed the validity and robustness of the Expectation Confirmation Model, Information Systems Success Model, and trust theory in online health management continuance. Moderators included but are not limited to age difference and service type. The elderly research in the healthcare context and other analytical methods such as qualitative comparative analysis should be applied in the future.

Asynchronous Remote Communication as a Tool for Care Management in Primary Care: A Rapid Review of the Literature

Aim:

To review the available evidence on asynchronous communication models between primary care professionals and patients in different countries around the world in order to analyse the added value that this model brings to patients and professionals.

Design:

A rapid literature review was conducted using the World Health Organisation guidance to include a variety of studies on the concept of asynchronous communications between primary care and patients in different countries.

Data sources:

The search for articles was carried out in PubMed and Google Academics and with the contribution of telemedicine experts from the Catalan Institute of Health.

Selection of studies:

The review included 271 articles. The inclusion criteria were: publications from 2010 onwards, in English, Spanish or Catalan, focused on asynchronous communications between primary care professionals and patients to improve patient management. After discarding duplicates and applying the exclusion criteria (255 articles), 16 were included for further review.

Data extraction:

The rapid literature review was conducted by an evaluator; detecting 5 main general themes: reduction of face-to-face visits, available services and most frequent uses, characteristics and perceptions of primary care professionals, characteristics and perceptions of users, and barriers and facilitators for the implementation of asynchronous teleconsultation.

Results:

A total of sixteen studies were included, including seven quantitative studies, seven qualitative studies and two mixed studies.

Conclusions:

The high degree of satisfaction of both users and professionals, the outbreak of COVID-19 and the effectiveness and efficiency of asynchronous remote communications are key factors for the implementation and improvement in the management of the different healthcare systems across the world.

Telemedicine and virtual respiratory care in the era of COVID-19

The World Health Organization defines telemedicine as “an interaction between a health care provider and a patient when the two are separated by distance”. The COVID-19 pandemic has forced a dramatic shift to telephone and video consulting for follow up and routine ambulatory care for reasons of infection control. Short Message Service (“text”) messaging has proved a useful adjunct to remote consulting allowing transfer of photographs and documents. Maintaining non-communicable diseases care is a core component of pandemic preparedness and telemedicine has developed to enable (for example) remote monitoring of sleep apnoea, telemonitoring of chronic obstructive pulmonary disease, digital support for asthma self-management, remote delivery of pulmonary rehabilitation. There are multiple exemplars of telehealth instigated rapidly to provide care for people with COVID-19, to manage the spread of the pandemic, or to maintain safe routine diagnostic or treatment services.

Despite many positive examples of equivalent functionality and safety, there remain questions about the impact of remote delivery of care on rapport and the longer-term impact on patient/professional relationships. Although telehealth has the potential to contribute to universal health coverage by providing cost-effective accessible care, there is a risk of increasing social health inequalities if the “digital divide” excludes those most in need of care. As we emerge from the pandemic, the balance of remote versus face-to-face consulting, and the specific role of digital health in different clinical and healthcare contexts will evolve. What is clear is that telemedicine in one form or another will be part of the “new norm”.

What are patients' first-time experiences with video consulting? A qualitative interview study in Danish general practice in times of COVID-19

OBJECTIVE

To explore the experiences of Danish patients using video consultation (VC) to consult their general practitioner (GP) during COVID-19 lockdown and their attitudes towards continued use beyond COVID-19.

DESIGN

A qualitative design was employed, consisting of individual semi-structured interviews where participants were asked to retrospectively describe their experiences and reflections. Data were analysed using thematic analysis.

SETTING

Capital and Southern Regions of Denmark.

PARTICIPANTS

27 patients (17 women and 10 men) aged between 23 and 76 years who had used VC once or more during the COVID-19 pandemic participated. The data were collected from February to October 2020. We used a convenience sampling technique and sample size was based on the principle of information power.

RESULTS

Three overarching themes, each containing subthemes, were developed. Participants described pre-use reactions and concerns relating to VC as being 'better than nothing' given the COVID-19 circumstances, and preferred VC over a telephone consultation. Salient pre-use concerns related to whether the technology 'would work' and whether VC would influence consultation length and GP behaviour. Overall, participants reported positive experiences of VC use and communication attributing these mainly to 'knowing the GP' and 'feeling seen and heard'. Participants were interested in future VC use for many needs as a natural consequence of an increasingly digitalised society, not least due to COVID-19.

CONCLUSIONS

Our findings contribute with knowledge about first-user experiences of VC against the background of COVID-19. Participants showed positive attitudes towards future use of VC as either a supplementary or alternative consultation form in general practice.

The Use of Electronic Consultations in Outpatient Surgery Clinics: Synthesized Narrative Review

BACKGROUND

Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning.

OBJECTIVE

We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19.

METHODS

We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults.

RESULTS

A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component.

CONCLUSIONS

The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.

Delivery of supported self-management in remote asthma reviews: A systematic rapid realist review

Background

The COVID‐19 pandemic forced health care systems globally to adapt quickly to remote modes of health care delivery, including for routine asthma reviews. A core component of asthma care is supporting self‐management, a guideline‐recommended intervention that reduces the risk of acute attacks, and improves asthma control and quality of life.

Objective

We aimed to explore context and mechanisms for the outcomes of clinical effectiveness, acceptability and safety of supported self‐management delivery within remote asthma consultations.

Design

The review followed standard methodology for rapid realist reviews. An External Reference Group (ERG) provided expert advice and guidance throughout the study. We systematically searched four electronic databases and, with ERG advice, selected 18 papers that explored self‐management delivery during routine asthma reviews.

Setting, Participants and Intervention

Health care professional delivery of supported self‐management for asthma patients during remote (specifically including telephone and video) consultations.

Main Outcome Measures

Data were extracted using Context‐Mechanism‐Outcome (C‐M‐O) configurations and synthesised into overarching themes using the PRISMS taxonomy of supported self‐management as a framework to structure the findings.

Results

The review findings identified how support for self‐management delivered remotely was acceptable (often more acceptable than in‐person consultations), and was a safe and effective alternative to face‐to‐face reviews. In addition, remote delivery of supported self‐management was associated with; increased patient convenience, improved access to and attendance at remote reviews, and offered continuity of care.

Discussion

Remote delivery of supported self‐management for asthma was generally found to be clinically effective, acceptable, and safe with the added advantage of increasing accessibility. Remote reviews could provide the core content of an asthma review, including remote completion of asthma action plans.

Conclusion

Our findings support the option of remote delivery of routine asthma care for those who have this preference, and offer healthcare professionals guidance on embedding supported self‐management into remote asthma reviews.

Patient and Public Contribution

Patient and public contribution was provided by a representative of the Asthma UK Centre for Applied Research (AUKCAR) patient and public involvement (PPI) group. The PPI representative reviewed the findings, and feedback and comments were considered. This lead to further interpretations of the data which were included in the final manuscript.

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.

How midwives implemented teleconsultations during the COVID-19 health crisis: a mixed-methods study

OBJECTIVES

Our primary and secondary objectives were to measure and understand the determinants of independent midwives' implementation of teleconsultations and their intention to continue these in the future.

DESIGN

A two-phase mixed-methods approach: (1) quantitative data to measure factors determining the initiation and continuation of teleconsultation, collected by an online survey from 29 April to 15 May 2020, at the end of the first COVID-19 lockdown, followed by (2) qualitative data to understand these determinants, by interviewing some participants in May-July 2020 to explore the quantitative findings in more detail.

SETTING

Mainland France PARTICIPANTS: The target population comprised independent midwives currently practising in France.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary and secondary outcomes were binary variables: implementation of teleconsultations, and intention to continue them. The qualitative results provided the themes explaining these decisions.

RESULTS

We obtained 1491 complete responses from independent midwives, that is, 28.3% of French independent midwives, and interviewed 22 volunteers among them. Among the 1491, 88.5% implemented teleconsultations and 65.8% intended to continue them. Both individual and organisational factors favoured implementation of teleconsultations: older age (adjusted OR (aOR): 0.40, 95% CI: 0.28 to 0.58), female gender (aOR: 6.88, 95% CI: 2.71 to 17.48), married or living with a partner (aOR: 1.67, 95% CI: 1.10 to 2.52) and working in a group practice (midwives only-aOR: 2.34, 95% CI: 1.47 to 3.72; multiprofessional group-aOR: 1.75, 95% CI: 1.16 to 2.64). The qualitative analysis did not identify any new factors but helped us to understand the satisfaction better: midwives adopted telemedicine for their patients' access to and continuity of care, to maintain their professional activity and income, and to limit the risks of infection.

CONCLUSION

Personal and organisational factors motivated the implementation of teleconsultation during the pandemic, but maintaining it raises technical, regulatory, and ethical issues.