Digital Health Digest: Curated by Dr. Jennifer Joe – Scaling Telehealth Video Consultations

JMIR Publications publishes 30 journals covering the breadth of digital health. The flagship title, Journal of Medical Internet Research, has been a leader Open Access for over 20 years and is the largest journal in the field.

In my role as JMIR Publications Chief Ambassador, my focus is translating knowledge and making traditional peer-reviewed scientific information and data more accessible. The goal of this series it to highlight excellent, evidence-based medicine for my digital health followers and enthusiasts, particularly those investing in related startups.

We should all be working towards meaningful digital health tools to improve patient care.

Without a doubt, the incredible infectiousness of the pandemic and consistent messaging to social distance pushed telehealth usage and adoption to an all-time high, and before Omicron, there were questions around if telehealth was here to stay. Clearly it is, so let’s talk more seriously around what scaling telehealth means and looks like.

First, let’s look at telehealth demand across the world. On February 19, 2021, Yih-Chung Tham, PhD (Singapore Eye Research Institute, Singapore) et al published, “Telehealth Demand Trends During the COVID-19 Pandemic in the Top 50 Most Affected Countries: Infodemiological Evaluation.” In this publication, the authors used an infodemiological approach to estimate the worldwide demand for telehealth services during COVID-19, focusing on the 50 most affected countries and comparing the demand for such services with the level of information and communications technology (ICT) infrastructure available.

The authors used telehealth-related internet searches as a surrogate marker of demand for telehealth and reported them as Relative Search Volumes (RSVs). The authors retrieved the information and communications technology (ICT) infrastructure index from the World Economic Forum Report.

Tham et al report that the mean demand for telehealth (RSV) was 18.5 and the mean technology infrastructure index (ICT) was 62.1 from January 1, 2020-July 7, 2020. Worldwide telehealth demand spiked from March 11, 2020 (demand peaked to 76.0), which then tailed off in June-July 2020 (mean demand was 25.8 during this period).

By country, 42 (84%) manifested increased demand over the evaluation period, with the highest demand observed in Canada (RSV=100) and the United States (RSV=96). When evaluating associations between RSV and the ICT index, both the United States and Canada demonstrated high telehealth demand (RSVs) and high IT infrastructure index (with ICT scores ≥70.3). In contrast, European countries had relatively lower telehealth demand (with RSVs range 3.4-19.5) despite high IT infrastructure (ICT index scores mean 70.3). Several Latin American (Brazil, Chile, Colombia) and South Asian (India, Bangladesh, Pakistan) countries demonstrated relatively higher telehealth demand (with RSVs range 13.8-73.3) but low IT infrastructure index (with ICT index scores mean 44.6), indicating that the telehealth demand outstrips the current IT infrastructure.

This study illustrates the demand for telehealth and underscores the critical importance of taking IT infrastructure into consideration as an important component of scaling up telehealth visits.

Recently, I interviewed corresponding author Trisha Greenhalgh, PhD (University of Oxford, Oxford, Great Britain) on her Journal of Medical Internet Research publication from October 7, 2021, “Expanding Video Consultation Services at Pace and Scale in Scotland During the COVID-19 Pandemic: National Mixed Methods Case Study.” In this publication, Dr. Greenhalgh looks at lessons learned from a national evaluation of the introduction, spread, and scale-up of Scotland’s video consultation services both before and during the pandemic.

Specifically, Dr. Greenhalgh utilizes the Planning and Evaluating Remote Consultation Services (PERCS) framework to illustrate the most important considerations for how to successfully roll out video consultations for different specialties, disease states, types of users (both clinicians and patients), phases of the clinician-patient relationship, and home situation. In general, the authors found that video consultations were used primarily for routine follow-up of chronic, stable conditions, especially to convey test results and affirm that the patient remained asymptomatic. For an example of digital literacy affecting the interaction, the authors found that patients with low digital literacy competency or confidences sometimes benefited from an on-hand carer to support the video consultation; and if that wasn’t available, the visit was often limited to telephone.

Overall, Scotland had done so much national-level groundwork before the pandemic that this allowed many services to rapidly extend the use of video consultations during the pandemic. The success was attributed to a strong strategic vision, a well-resourced quality improvement model, dependable technology, and multiple opportunities for staff to try out the video option.

To learn more, be sure to watch the full interview here -

In the publication, “Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction,” with corresponding author Sara E Shaw, PhD (University of Oxford, Oxford, Great Britain) and published on May 11, 2020, the authors evaluated 4 clinical settings across 2 trusts in the UK National Health Service to identify top problems and offer preliminary guidance on solutions.

Overall, the authors found that most consultations were technically and clinically unproblematic. However, 3 interactional challenges were identified: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination.

The authors found that for technical issues related to opening the video consultation or dealing with disruption to the conversational flow (audio or video issues), almost all issues could be resolved by working collaboratively together or by reverting to an established communication form to troubleshoot (like a telephone call).

The remote physical exam was more difficult and required the patient (and, in some cases, a relative) to simultaneously follow instructions and manipulate technology (eg, camera) to make it possible for the clinician to see and hear adequately. The authors suggest that there is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives.

As you can see by these studies, the demand for telehealth is high across this world from a pandemic that has affected all of us worldwide. We are all on this steep learning curve to figure out how to make telehealth work for both the clinician and the patient. Dr. Greenhalgh’s PERCS framework helps us structure how to think through the nuances of the different types of telehealth being delivered to the different types of patients. Dr. Shaw’s publication offers insight into the top problems experienced in the UK with the early rollout and makes useful suggestions. With time, the concept of virtual first healthcare may become the norm – the cost-effectiveness of this modality of care is already well-understood.

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