Esther Barsom

SUMMARY OF THE MAIN FINDINGS AND DISCUSSION

This thesis describes the implementation and scale up of VC at a tertiary referral center with two physical locations. The implementation was based on scientific research addressing patient- and provider needs and understanding their preferences.

Patients preferences towards using video consultation at the outpatient clinic
Patients preferences were studied in a national survey study in cooperation with the Netherlands Patients Federation (NPF) (chapter 1). Respondents were willing to use a VC for health purposes. The most important themes identified with willingness to use VC were associated with digital literacy (ability to establish a VC) and patient’s competences to share and understand health information (perceived provision of healthcare), also known as health literacy. Some patients had difficulties trusting the same quality of care would be provided over a video connection, due to the unfamiliarity with VC for health purposes. However, several regular outpatient consultations were considered eligible for VC.

Everything changed during the COVID-19 pandemic. Due to social distancing, the use of VC shifted from sporadic use by enthusiasts, to care at distance unless there was a medical need for physical consultation. Also referred to as ‘remote-by-default’. In chapter 7 we describe increased willingness and patient preference for VC during the COVID-19 pandemic, after patients had received a VC for health purposes. Out of all patients, 73% preferred a VC over a telephone consultation while only 6% preferred a TC over a VC.

Patient satisfaction with video consultation
After an extensive literature search as part of a systematic review, chapter 2 describes which questionnaire was most suitable to measure patients satisfaction with VC. This questionnaire formed the base of the questionnaires we used in chapter 3 and chapter 4 to assess patient satisfaction with VC compared to physical consultation and telephone consultation respectively.

In chapter 3, patient attitude and satisfaction with VC was compared to physical consultation during follow up at the outpatient surgical clinic. Fifty patients were allocated to either the VC-group or the F2F-group based on their personal preference. In total, 42% preferred a VC over a TC, which was consistent with the number of patients willing to use a VC in chapter 1. Patients who chose a VC, had more confidence in the ability of the healthcare provider to understand their healthcare condition over a video connection and underlined the benefits of using VC. Differences in satisfaction were observed in favor of VC and were related to asking more personal questions and explaining what to do when complaints do not disappear, although this outcome did not reach statistical significance. Almost all patients in the VC-group were willing to use VC again in the future, as did almost 40% within the F2F-group.

Chapter 4 describes patient satisfaction with VC compared to TC. Again, we asked 50 patients for their preference for either a VC or a TC. The number of patients who voluntarily chose a video consultation was consistent with the number of patients willing to use a video consultation in chapter 1 and choosing a video consultation in chapter 4. Patients underlined the beneficial aspect of visual feedback to both the surgeon and the patient. Most importantly patients felt the surgeon was better able to understand their wellbeing and meet their medical needs because of the presence of visual cues. All patients in the VC group were willing to use a video consultation for future follow up consultations, as did 20% of the patients in the TC group.

In chapter 7 we evaluated the use of VC during a pandemic. Almost 80% of the patients stated that VC had the same value as a physical appointment at the hospital, 90% thought a VC was a good solution to continue the provision of healthcare and over 70% was willing to use a VC in post pandemic times. However, some patients feared that VC would be considered standard practice after the pandemic and would therefore be used as a replacement rather than a substitute to care. As a consequence some mentioned the use of VC might have negative impact on the patient-provider relation by the lack of physical contact. In addition, the inability of specific patient groups (elderly, patients with low socio-economic status and non-native speakers) to use VC, was mentioned as an topic of concern.

Provider satisfaction with video consultation
Provider satisfaction was measured amongst surgeons when comparing VC with physical consultation in chapter 3. Surgeons were able to assess a patient’s medical condition over a video connection and did not consider the absence of physical contact a problem. The overall grade of satisfaction was high. Surgeons raised concerns towards the absence of physical examination within patients in the physical group, which might hamper clinical decision making. However, in the VC group, these concerns were not confirmed.

In chapter 4 we measured surgeon satisfaction with VC compared to telephone consultation. Surgeons indicated that the use of VC is more helpful in meeting the needs of their patients, resulting in higher patient satisfaction.

Chapter 7 describes the additional value of visual cues, especially when physical contact is restricted and the only alternative is contact over the telephone. In that case, a telephone consultation is solely preferred over a VC in case of a short follow-up call. For all other consultation types, visual cues and the ability to use inspection and read emotions, is considered beneficial over the convenience of using a telephone consultation. Close to 90% of the healthcare providers thought the use of VC was a good solution to continue the provision of healthcare during the pandemic, 82% intended to use VC in post-pandemic times, and 84% would encourage other colleagues to use VC.

The implementation of video consultation
In 2016 we started with the integration of Vidyo into our Electronic Health Record (EHR). In chapters 3 and 4 the usability of our VC system was rated as excellent by patients, mostly because of the user-friendliness, the reliability of the connection and the use of the patient portal. These chapters also reported high provider satisfaction with the VC solution because no additional IT time was required to set up the VC connection. As a result, workflow was not compromised and healthcare providers could deliver care tailored to the wishes of the patient without the additional burden of an altered workflow. However, in all studies performed within the scope of this thesis, patients and providers reported the necessity to include more common commercial functionalities like sharing a screen or inviting a third party.

Chapter 5 describes how we were able to successfully scale-up technically within four days during the pandemic, because the technical architecture was already in place. Chapter 7 describes how we scaled up physically from three outpatient clinics using video consultation to 83 departments within a few weeks. In chapter 6 we describe how we aimed to normalize the use of VC by fitting its use into the context of the organization and technical infrastructure by using schematic overviews. In addition, a clinical decision card was designed to support healthcare providers in deciding when to offer a VC (figure 1).

Figure 1. Clinical decision card on when to use video consultation

FUTURE PERSPECTIVES
Prior to the pandemic, the majority of healthcare professionals were under the impression that VC creates a lesser understanding of a patient’s wellbeing. Moreover, they were concerned a VC could not capture vital non-verbal cues. 1 As a consequence the majority of providers felt a VC was inferior to physical consultations.

The COVID-19 pandemic brought collateral advantages when it comes to the adoption of virtual care. It was only during the pandemic, that healthcare providers realized the benefits of VC. Not only in case of compromised physical interaction, 2 but also for post-pandemic times to reduce patient burden of (intensive) follow up. After having positive experiences when it comes to delivering care at a distance, most healthcare providers quickly put aside their initial resistance and adopted the use of VC. In addition, patients are more experienced with digital technology and more expectant than ever. The COVID-19 pandemic can therefore be considered a successful proof of concept.

If VC in the future will indeed become an important aspect of healthcare is yet to be discovered. This pandemic has paved the way like nothing else during the last decades could. The challenge for stakeholders and policy makers is to utilize the lessons learned from this pandemic to secure the use of VC in standard clinical practice in the future. However, there are still a few obstacles to overcome.

Implementation and scale-up
When it comes to the implementation and, ideally, the scale up of VC it is not one size fits all, not on national-, regional-, hospital- nor even on department level. Due to differences in team cultures, patient target groups, and workflow, implementing new technology is far from straightforward, and success is highly influenced by adoption at a large scale. In order to increase the adoption of VC, the use of VC should be aligned with existing work processes and management- and administrative structures. 3

Adoption of VC
VC is yet to be fully embraced by all healthcare providers and not just the early adopters. There are still some late adopters and laggards to be convinced of the advantages and possibilities of VC. The period of strict regulations might have been insufficient for these providers, and therefore first-hand experience is still lacking in this group. It is vital that positive experiences are shared by peers and that they become advocates for the structural use of VC. 4,5

Digital literacy
This pandemic taught us that a group of providers, and not just the elderly, are in need of help by offering targeted education and training. This also applies to an important group of patients. Prior to this pandemic, patients and providers with low digital literacy were not always identified because they could easily avoid to use VC because the context did not require it. Both were now ought to use VC, thereby exposing the impact of digital literacy. In order to future-proof VC, it is vital that stakeholders are aware of this impact. Their aim should be to prevent digital exclusion of certain patients and providers. 6

Adequate training possibilities and support
Every patient should be able to enjoy the benefits of receiving virtual care. In order to be able to establish equity when it comes to offering care at distance it is considered vital to guide both providers and patients by offering help and training possibilities. This might lead to an increase in addressing patient and provider concerns and can improve comfort in using VC to patients. Training opportunities should therefore be easily accessible. 7

Physical examination
Part of the general concern of using VC is the lack of the ability to perform physical examination. However, although findings might be more difficult to obtain over a video-connection, physical examination is possible to an extent. During a VC, the perceptual access is replaced by the patient’s observation and judgement. 8 This causes a shift in authority towards the patients, which fits in the current climate of self-efficacy and patient empowerment. 9 Once aware of this shift in authority, studies show that with some guidance and a more detailed patient history, physical examination via a video-connection provides enough information for clinical decision making. Hence, a VC should not be deemed inappropriate for every type of physical examination. Providers need to be educated on the possibilities of using physical examination over a video-connection.

Available technology
The integration of VC into the electronic health record (EHR) offers a lot of advantages. When embedding VC technology into the EHR, it is easier to ensure that regulatory requirements concerning data privacy, patient identification and verification and logistics of payment are met. Moreover, patient documentation is stored in one place. Although it might seem odd when comparing the use of video solutions with other commercial industries, these factors prevent a ‘plug-and-play’ solution in healthcare.

Start videoconsulten: Voor coronacrisis, Tijdens coronacrisis.
Integratie met Epic: Cloud oplossing, Deep integration, Doorgeleid naar externe omgeving.
Wie maken er gebruik van? Specialist, VPK, Consultent, AIOS, Paramedicus, ANIOS, Coassistent, VPK specialist.
Hardware zorgverleners: Laptop/PC zkh, Laptop/PC privé, iPad zkh, iPad privé, Android tablet zkh, Android tablet privé, iPhone zkh, iPhone privé, Android smartphone zkh, Android smartphone privé.
Hardware patiënt: Laptop/PC privé, iPad privé, Android tablet privé, iPhone privé, Android smartphone privé.
Functionaliteiten: 1. Chatfunctie, 2. Digitale wachtkamer, 3. Beeldscherm delen, 4. >2 deelnemers, 5. Opnemen voor zorgverlener, 6. Opnemen voor patiënt, 7. Anders.
Support zorgverlener, Support patiënt.
Aantal videoconsulten in April 2020: >300, 837, 1062, NVT, <100, 351, <100, 225, Onbekend. Totaal aantal VC: 10.000. Wat gaat goed? De integratie in de software, Kosten, Allocatie van tijd, Support vanuit poli, Zorgverleners maken er al gebruik van, Snelle uitrol, Commitment, snelle door Covid-19, Acceptatie voor zorgverlener en patiënt, Werkwijze van epd, Cisco lijkt stabiel, groepschat. Wat kan beter? Ondersteuning, Samenwerking, Gebruiksgemak, Meer resources, browser ondersteuning, Deep integration, Veel verschil in adoptie tussen poli’s, Enthousiasmeren van zorgverleners, Workarounds nodig, Helpdesk voor patiënten, digitale vaardigheden, kleiner scherm via smartphone, incheck probleem, procesniveau. Cijfer voor aanraden aan andere ziekenhuizen: 50, 65, 70, 80, 75. PRO: Ondersteuning type devices voor zowel zorgverlener als patiënt, meerdere functionaliteiten beschikbaar, support vanuit Zaurus is goed. Goede aansluiting bij het poli proces. Integratie in Hyperspace mogelijk. CON: Geen deep integration, niet alle browsers worden ondersteund, patiënt blijft niet binnen de MyChart omgeving. PRO: Werknemers zijn bekend met pexip, ondersteuning type devices voor zowel zorgverlener als patiënt. CON: Geen integratie met Epic, incheck probleem dus ook financiële afhandeling, bij updates soms traagheid. PRO: Deep integration mogelijk, zowel zorgverlener als patiënt blijven binnen Epic- en MyChart omgeving. CON: Aantal beschikbare lijnen, geen wachtkamer functie, Android devices niet ondersteund, audioprobleem. PRO: Prijs? Ondersteuning type devices voor zowel zorgverlener als patiënt. CON: Geen deep integration. PRO: Support vanuit Cisco, foto’s uploaden door zowel zorgverlener als patiënt, enquête uitsturen, folders of informatie delen met patiënt. CON: Niet alle browsers worden ondersteund, geen wachtkamerfunctie. PRO: Werknemers zijn bekend met Teams, ondersteuning type devices voor zowel zorgverlener als patiënt. CON: Geen deep integration, privacy. Versie 1.1, 13-07-2020, gegevens zijn gebaseerd op de gerapporteerde gegevens van de vermelde ziekenhuizen en zijn een reflectie van de periode april 2020. Contact: Reineke Kunze; r.m.kunze@amsterdamumc.nl of Esther Barsom; e.z.barsom@amsterdamumc.nl Figure 2. An overview of used VC software and available functionalities of 10 hospitals in the Netherlands Often, commercial video solutions are therefore not applicable to the healthcare setting because they lack integration possibilities with a EHR. As a consequence, hospital solutions are not fully developed and functionalities are restricted due to data security and privacy regulations. Even hospitals with the same EHR, use different solutions with a range of available functionalities, because of differences in technical infrastructure and requirements (figure 2). If we want the use of VC to be as easy as picking up the phone, commercial features (e.g. easily add a third party) should become available within the work field of the hospital. Guidelines Finally, it should be acknowledged that not all patient groups and health conditions would benefit equally from the use of VC. The nature of the condition, the clinical characteristics, the duration and severity of the condition all determine when a VC is suitable and appropriate for each appointment at each phase within a care pathway. 11 Guidelines should be developed to educate providers on the correct selection of consultations fit for VC and reciprocal benefits. Ideally, these guidelines are developed by specialties for specific conditions and their care pathways. The primary objective should be to provide the right care, in the right place, at the right time. Where possible, shared-decision making should be used to choose the kind of consultation scheduled. Such guidelines must also consider important aspects such as digital health literacy, patient and provider authentication, privacy and ethics. CONCLUSION This thesis indicates that the use of VC for outpatient care appointments is feasible, and accepted by both patients as well as providers without a detriment to the quality of care provided. There are still a few difficulties that hamper the structural use of video consultation in clinical practice today. But as soon as “Why?” becomes, “Why did we not do this before?”, we can work towards a climate in which receiving care at the right moment, at the right place can be supported by the convenience of digital care.