Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study (Preprint)

Abstract

BACKGROUND There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. OBJECTIVE The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model. METHODS A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). RESULTS When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. CONCLUSIONS Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

“…Most such studies lacked descriptive detail; both the clinical condition and the technology were often described in bland and brief ways, omitting the nuances that might have explained variations in findings across studies ( 116 ). The few detailed real-world studies in the literature suggest that efforts to implement remote consultation services even without an ongoing pandemic are logistically complex, resource-intensive and often stymied by technical and regulatory challenges ( 18 , 26 , 27 , 115 , 117 , 118 ). Levels of remote consulting outside the research setting were very low pre-pandemic ( 12 , 13 , 119 ).…”

“…Prior to the pandemic, we studied the organizational challenges associated with roll-out of video consultations across multiple clinical directorates in the UK's largest acute hospital trust (25)(26)(27), including sub-studies on physical examination by video (28,29). We also undertook contract research for the Scottish Government to evaluate the national roll-out of video consultations-an initiative that was driven partly by the policy goal of reducing carbon footprint and travel costs from remote settings (30).…”

Lavorare insieme per la salute: dalla multiprofessionalità alla transdisciplinarità

“…Tale approccio è inteso pertanto a migliorare l'accesso ai servizi sanitari, l' efficacia e l' efficienza delle cure fornite. Tuttavia, come sottolineato da Greenhalgh e colleghi, la complessità delle tecnologie digitali può rappresentare una sfida alla loro implementazione e loro efficace utilizzo (Greenhalgh et al, 2017).…”