Understanding the integration of artificial intelligence in healthcare organisations and systems through the NASSS framework: a qualitative study in a leading Canadian academic centre.

BACKGROUND: Artificial intelligence (AI) technologies are expected to "revolutionise" healthcare. However, despite their promises, their integration within healthcare organisations and systems remains limited. The objective of this study is to explore and understand the systemic challenges and implications of their integration in a leading Canadian academic hospital. METHODS: Semi-structured interviews were conducted with 29 stakeholders concerned by the integration of a large set of AI technologies within the organisation (e.g., managers, clinicians, researchers, patients, technology providers). Data were collected and analysed using the Non-Adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework. RESULTS: Among enabling factors and conditions, our findings highlight: a supportive organisational culture and leadership leading to a coherent organisational innovation narrative; mutual trust and transparent communication between senior management and frontline teams; the presence of champions, translators, and boundary spanners for AI able to build bridges and trust; and the capacity to attract technical and clinical talents and expertise. Constraints and barriers include: contrasting definitions of the value of AI technologies and ways to measure such value; lack of real-life and context-based evidence; varying patients' digital and health literacy capacities; misalignments between organisational dynamics, clinical and administrative processes, infrastructures, and AI technologies; lack of funding mechanisms covering the implementation, adaptation, and expertise required; challenges arising from practice change, new expertise development, and professional identities; lack of official professional, reimbursement, and insurance guidelines; lack of pre- and post-market approval legal and governance frameworks; diversity of the business and financing models for AI technologies; and misalignments between investors' priorities and the needs and expectations of healthcare organisations and systems. CONCLUSION: Thanks to the multidimensional NASSS framework, this study provides original insights and a detailed learning base for analysing AI technologies in healthcare from a thorough socio-technical perspective. Our findings highlight the importance of considering the complexity characterising healthcare organisations and systems in current efforts to introduce AI technologies within clinical routines. This study adds to the existing literature and can inform decision-making towards a judicious, responsible, and sustainable integration of these technologies in healthcare organisations and systems.

The reflexive imperative in the digital age: Using Archer's 'fractured reflexivity' to theorise widening inequities in UK general practice.

'Reflexivity', as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer's theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from 'Deep End' practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients' reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients' fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care.

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

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

Clinical context and communication in shared decision-making about major surgery: Findings from a qualitative study with colorectal, orthopaedic and cardiac patients.

Increasing numbers of older people undergo major surgery in the United Kingdom (UK), with many at high risk of complications due to age, co-morbidities or frailty. This article reports on a study of such patients and their clinicians engaged in shared decision-making. Shared decision-making is a collaborative approach that seeks to value and centre patients' preferences, potentially addressing asymmetries of knowledge and power between clinicians and patients by countering medical authority with greater patient empowerment. We studied shared decision-making practices in the context of major surgery by recruiting 16 patients contemplating either colorectal, cardiac or joint replacement surgery in the UK National Health Service (NHS). Over 18 months 2019-2020, we observed and video-recorded decision-making consultations, studied the organisational and clinical context for consultations, and interviewed patients and clinicians about their experiences of making decisions. Linguistic ethnography, the study of communication and interaction in context, guided us to analyse the interplay between interactions (during consultations between clinicians, patients and family members) and clinical and organisational features of the contexts for those interactions. We found that the framing of consultations as being about life-saving or life-enhancing procedures was important in producing three different genres of consultations focused variously on: resolving problems, deliberation of options and evaluation of benefits of surgery. We conclude that medical authority persists, but can be used to create more deliberative opportunities for decision-making through amending the context for consultations in addition to adopting appropriate communication practices during surgical consultations.

Video analysis of communication by physiotherapists and patients in video consultations: a qualitative study using conversation analysis.

OBJECTIVES: To investigate the challenges of doing physical examinations and exercises by video, and the communication strategies used by physiotherapists and patients to overcome them. DESIGN: A qualitative study of talk and social actions, examining the verbal and non-verbal communication practices used by patients and physiotherapists. Video consultations between physiotherapists and patients were video recorded using MS Teams, transcribed and analysed in detail using Conversation Analysis. SETTING: Video consultations were recorded in three specialist settings (long-term pain, orthopaedics, and neuromuscular rehabilitation) across two NHS hospitals. PARTICIPANTS: 15 adult patients (10 female, 5 male; aged 20-77) with a scheduled video consultation. RESULTS: Examinations and exercises retain-->were successfully accomplished in all 15 consultations. Two key challenges were identified for physiotherapists and patients when doing video assessments: (1) managing safety and clinical risk, and (2) making exercises and movements visible. Challenges were addressed by through communication practices that were patient-centred and tailored to the video context (e.g., explaining how to frame the body to the camera or adjust the camera to make the body visible). CONCLUSIONS: Video is being used by physiotherapists to consult with their patients. This can work well, but tailored communication strategies are critical to help participants overcome the challenges of remote physical examinations and exercises. CONTRIBUTION OF THE PAPER: This paper is a first to use video-based analysis to determine the challenges of video consulting for doing remote assessments and exercises in physiotherapy settings. It demonstrates how patients and physiotherapists use communication strategies to raise concerns around safety and visibility and how they overcome these concerns.

Training needs for staff providing remote services in general practice: a mixed-methods study.

BACKGROUND: Contemporary general practice includes many kinds of remote encounter. The rise in telephone, video and online modalities for triage and clinical care requires clinicians and support staff to be trained, both individually and as teams, but evidence-based competencies have not previously been produced for general practice. AIM: To identify training needs, core competencies, and learning methods for staff providing remote encounters. DESIGN AND SETTING: Mixed-methods study in UK general practice. METHOD: Data were collated from longitudinal ethnographic case studies of 12 general practices; a multi-stakeholder workshop; interviews with policymakers, training providers, and trainees; published research; and grey literature (such as training materials and surveys). Data were coded thematically and analysed using theories of individual and team learning. RESULTS: Learning to provide remote services occurred in the context of high workload, understaffing, and complex workflows. Low confidence and perceived unmet training needs were common. Training priorities for novice clinicians included basic technological skills, triage, ethics (for privacy and consent), and communication and clinical skills. Established clinicians' training priorities include advanced communication skills (for example, maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, coordinating multi-professional care in a distributed environment, and training others. Much existing training is didactic and technology focused. While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements were usually acquired through experience, informal discussions, and on-the-job methods such as shadowing. Whole-team training was valued but rarely available. A draft set of competencies is offered based on the findings. CONCLUSION: The knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective, and organisationally embedded. The vital role of non-didactic training, for example, joint clinical sessions, case-based discussions, and in-person, whole-team, on-the-job training, needs to be recognised.

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

BACKGROUND: Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. SETTING AND SAMPLE: UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. METHODS: Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts. RESULTS: Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. CONCLUSION: While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

Mobilising context as complex and dynamic in evaluations of complex health interventions.

BACKGROUND: The relationship between healthcare interventions and context is widely conceived as involving complex and dynamic interactions over time. However, evaluations of complex health interventions frequently fail to mobilise such complexity, reporting context and interventions as reified and demarcated categories. This raises questions about practices shaping knowledge about context, with implications for who and what we make visible in our research. Viewed through the lens of case study research, we draw on data collected for the Triple C study (focused on Case study, Context and Complex interventions), to critique these practices, and call for system-wide changes in how notions of context are operationalised in evaluations of complex health interventions. METHODS: The Triple C study was funded by the Medical Research Council to develop case study guidance and reporting principles taking account of context and complexity. As part of this study, a one-day workshop with 58 participants and nine interviews were conducted with those involved in researching, evaluating, publishing, funding and developing policy and practice from case study research. Discussions focused on how to conceptualise and operationalise context within case study evaluations of complex health interventions. Analysis focused on different constructions and connections of context in relation to complex interventions and the wider social forces structuring participant's accounts. RESULTS: We found knowledge-making practices about context shaped by epistemic and political forces, manifesting as: tensions between articulating complexity and clarity of description; ontological (in)coherence between conceptualisations of context and methods used; and reified versions of context being privileged when communicating with funders, journals, policymakers and publics. CONCLUSION: We argue that evaluations of complex health interventions urgently requires wide-scale critical reflection on how context is mobilised - by funders, health services researchers, journal editors and policymakers. Connecting with how scholars approach complexity and context across disciplines provides opportunities for creatively expanding the field in which health evaluations are conducted, enabling a critical standpoint to long-established traditions and opening up possibilities for innovating the design of evaluations of complex health interventions.

The Role of Virtual Consulting in Developing Environmentally Sustainable Health Care: Systematic Literature Review.

BACKGROUND: Health systems globally need to rapidly set and achieve targets for reaching net zero carbon emissions. Virtual consulting (including video- and telephone-based consulting) is regarded as one means by which this might be achieved, largely through reduced patient travel. Little is currently known about the ways in which forms of virtual consulting might contribute to the net zero agenda or how countries may develop and implement programs at scale that can support increased environmental sustainability. OBJECTIVE: In this paper, we asked, What is the impact of virtual consulting on environmental sustainability in health care? and What can we learn from current evaluations that can inform future reductions in carbon emissions? METHODS: We conducted a systematic review of published literature according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. We searched the MEDLINE, PubMed, and Scopus databases using key terms relating to "carbon footprint," "environmental impact," "telemedicine," and "remote consulting," using citation tracking to identify additional articles. The articles were screened, and full texts that met the inclusion criteria were obtained. Data on the approach to carbon footprinting reported reductions in emissions, and the opportunities and challenges associated with the environmental sustainability of virtual consultations were extracted into a spreadsheet, analyzed thematically, and theorized using the Planning and Evaluating Remote Consultation Services framework to consider the various interacting influences, including environmental sustainability, that shape the adoption of virtual consulting services. RESULTS: A total of 1672 papers were identified. After removing duplicates and screening for eligibility, 23 papers that focused on a range of virtual consulting equipment and platforms across different clinical conditions and services were included. The focus on the environmental sustainability potential of virtual consulting was unanimously reported through carbon savings achieved by a reduction in travel related to face-to-face appointments. The shortlisted papers used a range of methods and assumptions to determine carbon savings, reporting these using different units and across varied sample sizes. This limited the potential for comparison. Despite methodological inconsistencies, all papers concluded that virtual consulting significantly reduced carbon emissions. However, there was limited consideration of wider factors (eg, patient suitability, clinical indication, and organizational infrastructure) influencing the adoption, use, and spread of virtual consultations and the carbon footprint of the entire clinical pathway in which the virtual consultation was provided (eg, risk of missed diagnoses from virtual consultations that result in the need for subsequent in-person consultations or admissions). CONCLUSIONS: There is overwhelming evidence that virtual consulting can reduce health care carbon emissions, largely through reducing travel related to in-person appointments. However, the current evidence fails to look at system factors associated with implementing virtual health care delivery and wider research into carbon emissions across the entire clinical pathway.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions.

BACKGROUND: Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions. METHODS: A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice. RESULTS: We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest. CONCLUSION: The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study.

BACKGROUND: Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. METHODS: This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery. RESULTS: Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory. CONCLUSIONS: Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.

The 'wrong pocket' problem as a barrier to the integration of telehealth in health organisations and systems.

The COVID-19 pandemic has accelerated the deployment of telehealth services in many countries around the world. It also revealed many barriers and challenges to the use of digital health technologies in health organisations and systems that have persisted for decades. One of these barriers is what is known as the 'wrong pocket' problem - where an organisation or sector makes expenditures and investments to address a given problem, but the benefits (return on investment) are captured by another organisation or sector (the wrong pocket). This problem is the origin of many difficulties in public policies and programmes (e.g. education, environment, justice and public health), especially in terms of sustainability and scaling-up of technology and innovation. In this essay/perspective, we address the wrong pocket problem in the context of a major telehealth project in Canada. We show how the problem of sharing investments and expenses, as well as the redistribution of economies among the different stakeholders involved, may have threatened the sustainability and scaling-up of this project, even though it has demonstrated the clinical utility and contributed to improving the health of populations. In conclusion, the wrong pocket problem may be decisive in the reduced take-up, and potential failure, of certain telehealth programmes and policies. It is not enough for a telehealth service to be clinically relevant and 'efficient', it must also be mutually beneficial to the various stakeholders involved, particularly in terms of the equitable sharing of costs and benefits (return on investment) associated with the implementation of this new service model. Finally, the wrong pocket concept offers a helpful lens for studying the success, sustainability, and scale-up of digital transformations in health organisations and systems. This needs to be considered in future research and evaluations in the field.

An urgent call for the environmental sustainability of health systems: A 'sextuple aim' to care for patients, costs, providers, population equity and the planet.

Health systems have a duty to protect the health and well-being of individuals and populations. Yet, healthcare contributes about 4.6% of global greenhouse gas emissions. Health systems need to question and improve established practices, assume strong environmental leadership, and aim for ambitious, sometimes radical, actions in favour of the climate. In this paper, we interrogate the suitability and feasibility of integrating the aim of 'environmental sustainability' to form the 'Sextuple Aim.' Environmental sustainability may be in tension with, but also a potential lever to meet the other cardinal aims: (1) quality and experience of patient care; (2) population health; (3) quality of work and satisfaction of healthcare providers; (4) equity and inclusion; and (5) cost reduction. We propose policy and practical avenues to help move towards the Sextuple Aim.

Pharmaceutical Company Targets and Strategies to Address Climate Change: Content Analysis of Public Reports from 20 Pharmaceutical Companies.

The pharmaceutical industry produces a large proportion of health system greenhouse gas (GHG) emissions, contributing to climate change. This urgently needs to be addressed. We aimed to examine pharmaceutical company climate change targets, GHG emissions, and strategies to reduce them. We performed content analysis of the 20 largest pharmaceutical companies' publicly available 2020/2021 reports, focusing on extracting information on their reported climate change targets, GHG emissions (and whether companies had demonstrated any reduction in emissions over their reporting period), and strategies being implemented to reduce company emissions and meet their targets. Nineteen companies have committed to reducing GHG emissions, ten to carbon neutrality and eight to net zero emissions between 2025 and 2050. Companies showed largely favorable reductions in scope 1 (in-house) and scope 2 (purchased energy), with variable results in scope 3 (supply chain) emissions. Strategies to reduce emissions included optimizing manufacturing and distribution, and responsible sourcing of energy, water, and raw materials. Pharmaceutical companies are setting climate change targets and reporting reduced emissions via a range of strategies. This varies, with scope to track actions and accountability to targets, improve consistency of reporting, especially of scope 3 emissions, and collaborate on novel solutions. There is need for further mixed methods research on progress with achieving reported climate change targets, as well as implementation of strategies to reduce emissions within the pharmaceutical industry.

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

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.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients.

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This "perspective" paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations' access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the "solution to everything". In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial "Direct-To-Consumer" services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to "capabilities" supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing "public health value" through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research.

BACKGROUND: The COVID-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice. AIM: To develop an empirically based and theory-informed taxonomy of risks associated with remote consultations. DESIGN & SETTING: Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice before and during the COVID-19 pandemic in the UK. METHOD: Semi-structured interviews and focus groups, with a total of 176 clinicians and 43 patients. Data were analysed thematically, taking account of an existing framework of domains of clinical risk. RESULTS: The COVID-19 pandemic brought changes to estates (for example, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to the following: (1) practice set-up and organisation (including digital inequalities of access, technology failure, and reduced service efficiency); (2) communication and the clinical relationship (including a shift to more transactional consultations); (3) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation, and over-treatment); (4) increased burden on the patient (for example, to self-examine and navigate between services); (5) reduced opportunities for screening and managing the social determinants of health; and (6) workforce (including increased clinician stress and fewer opportunities for learning). CONCLUSION: Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting, and training and support for staff.

Why do GPs rarely do video consultations? qualitative study in UK general practice.

BACKGROUND: Fewer than 1% of UK general practice consultations occur by video. AIM: To explain why video consultations are not more widely used in general practice. DESIGN AND SETTING: Analysis of a sub-sample of data from three mixed-method case studies of remote consultation services in various UK settings from 2019-2021. METHOD: The dataset included interviews and focus groups with 121 participants from primary care (33 patients, 55 GPs, 11 other clinicians, nine managers, four support staff, four national policymakers, five technology industry). Data were transcribed, coded thematically, and then analysed using the Planning and Evaluating Remote Consultation Services (PERCS) framework. RESULTS: With few exceptions, video consultations were either never adopted or soon abandoned in general practice despite a strong policy push, short-term removal of regulatory and financial barriers, and advances in functionality, dependability, and usability of video technologies (though some products remained 'fiddly' and unreliable). The relative advantage of video was perceived as minimal for most of the caseload of general practice, since many presenting problems could be sorted adequately and safely by telephone and in-person assessment was considered necessary for the remainder. Some patients found video appointments convenient, appropriate, and reassuring but others found a therapeutic presence was only achieved in person. Video sometimes added value for out-of-hours and nursing home consultations and statutory functions (for example, death certification). CONCLUSION: Efforts to introduce video consultations in general practice should focus on situations where this modality has a clear relative advantage (for example, strong patient or clinician preference, remote localities, out-of-hours services, nursing homes).

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

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