The Role of Information Infrastructures in Scaling up Video Consultations During COVID-19: Mixed Methods Case Study Into Opportunity, Disruption, and Exposure

Abstract

Background Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a “burning platform” for scaling up such services. As health care organizations look to expand and maintain the use of video in the “new normal,” it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward. Objective This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19. Methods A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants (eg, clinicians, managers, administrators, and IT support), ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al’s 3 perspectives on crisis and digital change: as opportunity (for accelerated innovation and removal of barriers to experimentation), disruption (to organizational practices, generating new dependencies and risks), and exposure (of vulnerabilities in both people and infrastructure). Results Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an “organizing vision” for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use. Conclusions For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed.

Remote care in UK general practice: baseline data on 11 case studies

“…Research and surveys undertaken by others in 2021-2022 affirmed a number of findings of this familiarisation phase, including problems of accessing primary care 29 ; substantially increased workload in UK primary care 30 ; perceptions by GPs of increased clinical risk with some remote consultations 31 , 32 or when patients are encouraged to monitor their own chronic conditions such as blood pressure and report by telephone 33 ; exacerbation of inequities, especially among the most vulnerable groups, as services went digital 34 – 40 ; a primary care workforce that is increasingly stressed and underconfident 41 – 44 ; multiple infrastructural challenges to establishing remote services during the pandemic 45 – 48 ; and challenges to patient input to research efforts during the pandemic 49 .…”

The Role of Human and Organizational Factors in the Pursuit of One Digital Health

“…As expected, our review saw a range of studies focusing on different technologies and across different system levels. Many of the surveyed papers studied HOFs using specific technologies including mental health consultation [20,21], online consultations [22,32], clinical decision support systems (CDSS) [23], electronic medication management systems [24], video consultation [25][26], aged care systems [27] and telemedicine [36]. The context of use for these systems included hospitals [23,[28][29][30][31][32][33][34], residential aged care homes [27], and community health facilities [35].…”

“…When HIT fails to adequately support teamwork we see workarounds or manual processes such as for data transfer or other tasks, which leads to a significant administrative burden on clinical teams [50]. While we often transition or scale processes from the micro to the meso level [49,53], we can also use blended approaches that start at the team or organizational level and then scale down to individuals [25,49].…”

“…Developed -A common theme in our survey was the challenge in moving from individual to team or collaborative tasks [25,44,49,53]. On one hand, ODH really is collaborative care delivery at a very large scale, but we cannot design and evaluate collaborative systems from an individual user perspective and expect it to scale up to support teambased care.…”

“…Harahap studied personal health record adoption in Indonesia and showed that while individual and technological factors impact PHR adoption, so do organizational factors [35]. Scale up of video consultations requires a mix of top down and bottom-up approaches to ensure systems have technical dependability but also are aligned with the social and cultural context where they will be used [25]. Mitigating negative unintended consequences from online consultation systems requires integration with the technical systems (e.g., software) and with organizational workflows [22].…”