Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study
Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study
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DOI：
10.2196/jmir.9897
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发表时间：
2018-04-01
影响因子：
7.4
通讯作者：
Hodkinson, Isabel
中科院分区：
文献类型：
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作者：
Greenhalgh, Trisha;Shaw, Sara;Hodkinson, Isabel
背景：人们对使用视频技术的虚拟咨询很感兴趣。随机对照试验表明，视频咨询在选定的条件和情况下是可接受的，安全的，有效的。然而，这种模式很少被主流化和持续在现实世界setting.Objective：这项研究试图（1）定义良好的做法，并告知视频门诊咨询的实施和（2）产生可转移的知识，扩大和推广这种服务模式的挑战。Skype视频咨询的多层次，混合方法研究（微观一级）纳入了组织案例研究（中观一级），同时考虑到国家背景和更广泛的影响（宏观一级）。这项研究是在英国伦敦的一家国家卫生服务信托基金（涵盖三家医院）的三项临床服务（糖尿病、糖尿病产前和癌症手术）中引入视频门诊咨询后进行的。数据来源包括36个国家一级的利益攸关方（探索性和半结构化访谈），纵向组织人种志（300小时的观察; 24名工作人员访谈），30个录像远程磋商，17个录音面对面的磋商，以及国家和地方文件。定性数据，使用社会技术变革理论分析，解决工作人员和病人的经验和组织和系统的驱动程序。定量数据，通过描述性统计分析，包括摄取的工作人员和患者的视频咨询和不同类型的谈话的微分类（使用Roter互动分析系统）。结果：当临床，技术和实际的前提条件得到满足，视频咨询出现安全，并受到一些患者和工作人员的欢迎。与类似情况下的面对面咨询相比，视频咨询的时间略短，患者的谈话时间略长，双方有时需要做出明确的事情，而这些事情在传统的会面中通常是含蓄的。当临床医生和患者已经相互了解和信任时，视频咨询似乎效果更好。一些临床医生使用Skype自适应地回应患者的临时会面请求，似乎加强了支持的自我管理。在一个忙碌和财政紧张的急性医院环境中建立视频门诊服务的现实证明比最初预期的更复杂和耗时。到本研究结束时，2%至22%的咨询由参与临床医生远程进行。在其余的，临床医生选择不参加，或视频咨询被认为是不切实际的，技术上无法实现的，或临床上不可取的。技术挑战通常是轻微的，但可能prohibitory.Conclusions：视频门诊咨询出现安全，有效，方便的情况下，参与临床医生判断他们的临床适当的患者，但这种情况下是一小部分的整体诊所工作量。与其他技术创新一样，一些临床医生会欣然接受，而其他人则需要激励和支持。在那些不愿改变的组织中，尤其是在紧缩时期，将视频咨询服务嵌入日常实践中面临着复杂的挑战。
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.