key: cord-1029614-60nvz07y
authors: Thomas, Emma; de Camargo Catapan, Soraia; M Haydon, Helen; Barras, Michael; Snoswell, Centaine
title: Exploring factors of uneven use of telehealth among outpatient pharmacy clinics during COVID-19: A multi-method study()
date: 2022-02-09
journal: Res Social Adm Pharm
DOI: 10.1016/j.sapharm.2022.02.003
sha: 2cd9c6c381f23be420c1b35817b118f4ab53c38b
doc_id: 1029614
cord_uid: 60nvz07y

BACKGROUND: To enable services to be provided at a distance during the COVID-19 pandemic, outpatient pharmacy services in Australia underwent near-immediate reform by moving to telehealth, including telephone and video consult. OBJECTIVE: To investigate how telehealth was used in a metropolitan outpatient pharmacy setting before and after the start of the COVID-19 restrictions and the various influences on the uptake of phone and video modalities. METHODS: A multi-methods approach was used including: (1) quantifying administrative activity data between July 2019 to December 2020 and, (2) semi-structured interviews with key stakeholders (n = 34). RESULTS: Activity data: Between July 2019 to December 2020 16,377 outpatient pharmacy consults were provided. Of these, 13,543 (83%) were provided in-person, 2,608 (16%) by telephone and 226 (1.4%) by video consult. COVID-19 impacted how these services were provided with telephone activity more than four-times higher in April 2020 than March 2020 and slight increases in video consults. Pharmacists have heavily favoured using the telephone despite the recommendation that video consults be used as the primary mode of contact and that telephone only be used when video consult was not possible. As soon as COVID-19 restrictions eased, clinicians gradually returned to in-person appointments, maintaining some use of telephone and very limited use of video consult. Semi-structured interviews: Whilst clinicians recognised the potential benefits of video consults, challenges to routine use included the additional administrative and planning work required pre-consult, perceptions that patients were unable to use the technology, and the belief that in-person care was ‘better’ and that the telephone was easier. CONCLUSION: Organisational strategies that encouraged the use of video over telephone (e.g. through financial incentives) did not appear to influence clinicians’ choice of care modality. Implementation studies are required to co-develop solutions to embed telehealth options into outpatient pharmacy settings that provide the best experience for both patients and clinicians.

Pharmacists play a key role in medication management both in hospitals and the community, 1-3 and 32 increasingly in outpatient specialist clinics. 4, 5 In 2020, Australia, like many countries, saw a rapid change in 33 the way that healthcare was delivered, with many clinicians swapping in-person consultations for 34 synchronous telehealth (telephone or video consults) to reduce the risk of COVID-19 transmission. 6,7 Many 35 outpatient pharmacy services underwent near-immediate reform as services were required to physically 36 distance patients and staff, this meant changing in-person services to telehealth where appropriate. 37

Despite Government recommendations that video consults be used as the primary mode of telehealth 38 contact and that telephone only be used when video consults were not possible, 8 approximately 90% of all 39

Australian telehealth consultations in 2020 (including general practitioners, allied health and nursing 40 J o u r n a l P r e -p r o o f services) occurred using the telephone. 9 While the long-term effects of these changes remain to be seen, the 41 COVID-19 pandemic has presented an exceptional natural experiment where clinician adoption of telehealth 42

can be observed. 43

In the 2019-2020 financial year, the PAH executive made a multi-million-dollar investment by adding new 44 outpatient pharmacist roles across renal, cancer, mental health, surgery, general medical, and emergency 45 medicine, as well as rehabilitation services. It was expected that the addition of a pharmacist to these teams 46 would enhance medication compliance, prevent medication-related harm, and improve patient outcomes. 47

This research was conducted as part of the overall evaluation for these clinical roles. 27, 28 This paper explores 48 the changes to the modality of care across pharmacist outpatient clinics at a large metropolitan hospital 49 during and immediately after the peak COVID-19 restrictions that occurred between March and May 2020 in 50

Queensland, Australia. At this hospital, clinicians have access to telehealth support, software, and 51 infrastructure to conduct video consults. 52

Using complimentary administrative activity data and qualitative interviews with pharmacists, their team 53 leaders, managers, and other clinical staff from the outpatient clinics, this paper examines the influences on 54

choosing the mode of delivery in lieu of in-person consultations. Specifically, this paper aims to: (1) determine 55 the proportion of outpatient pharmacy appointments that were delivered via telephone and video consult 56 before and after the start of the COVID-19 restrictions; and (2) understand the perceived clinician, service, 57

and broader contextual challenges to using video consults within the outpatient pharmacy setting. 58 59 Method 60 To achieve the study aims, a multi-methods approach was used including administrative activity data analysis 61 and semi-structured interviews with key stakeholders. Interview data collection 101 All participants were sent an information and consent form, and a demographics questionnaire ahead of their 102

interviews. If they were unable to return these prior to the interview, verbal consent was obtained at the 103 start of the interview. Interviews were conducted in June-July 2020, via telephone, video consult, or in-person 104 depending on the availability of the participant and in line with the physical distancing restrictions in effect 105 at the time. An independent female research assistant (MT), who is experienced in qualitative research and 106

works separately from the pharmacy department and was not known to the participants, conducted all 107 interviews. No one else was present besides the participant and researcher. The full interviews explored the 108 benefits, enablers and challenges of the new pharmacist outpatient roles. Interviews were expected to take 109 20 to 30 minutes, but generally ranged between 30 to 60 minutes (median 33:44 minutes). Repeat interviews 110

were not carried out nor were transcripts or findings returned to the participants for comment. Here, we 111 analyse a subset of questions related to a change in modality of care due to the COVID-19 pandemic. This 112 subset comprised participant answers and comments related to the last two questions of the interview guide: 113

(1) How have your outpatient clinics changed as a result of the COVID-19 pandemic? (Prompt: the physical 114 distancing restriction); (2) Many services have swapped to telephone or video consult as a result of COVID-115 19 pandemic. Have you been using either of these? (Prompt: how was the transition? How has it been 116 working? If not, why not?). Each interview was audio-recorded and transcribed verbatim. 117

118 Interviews were audio recorded and automatically transcribed using HappyScribe software 119 (happyscribe.com). Transcripts were then checked for accuracy and deidentified by a member of the research 120 team. As guided by Saldaña, 12 the qualitative analysis was divided into two cycles of coding and an 121 intermediate step. The choice of codes for each cycle was guided by the research question. In the first cycle, 122 descriptive codes, which summarise data extracts into short words or phrases, were combined with structural 123 codes, which compared the data back to the interview questions and either realign or create new codes. 124

After the first cycle, the codes were revised, adjusted, grouped and the main essence of the identified codes 125 was described. In the second cycle of coding, we adopted the axial coding strategy to organise and 126 reassemble data, selecting the best representative categories that corresponded to the two themes: changes 127 and the influences on choice of telehealth modality of care as consequence of COVID-19. Throughout the 128 whole coding process, analytic memos (e.g. emerged patterns, code choice, inter-relations) were taken to 129 enable a reflexive analysis on the data set. 12 A sample of 15% and 30% of the data set were coded by two 130 independent researchers to ensure that coding reflected consistent and appropriate interpretation. Four 131

peer-debriefing and consensus meetings were conducted during the data analysis stage to discuss the codes, 132 analysis process and data saturation. NVivo for Mac version 12.6 was used to organise data analyses. 133 J o u r n a l P r e -p r o o f Trustworthiness and rigour 134 According to Guba (1981) , 13 trustworthiness of qualitative research has four constructs: credibility, 135 transferability, dependability and confirmability. Credibility of the study was enhanced by three of the 136 authors (CS, SC, MB) being clinical pharmacists with hospital pharmacy expertise, two of which were 137 employed by the study site (CS, MB). While these pharmacists were knowledgeable about the setting in which 138 the study took place, they were not involved in clinical pharmacy activities at the time of the study. 139

Transferability within the pharmacy setting it can be enhanced by including other health professionals. 14 This 140 study involved 34 staff from 16 unique clinics and included pharmacists, team leaders, nurses, and doctors. 141

The inclusion of a range of perspectives from different pharmacy clinics, disciplines and staff seniority 142 enabled the collection of broader viewpoints. Dependability was ensured by employing an independent 143 research assistant (MT) to conduct the interviews who was not a member of the hospital team or familiar 144 with any of the participants. Likewise, analyse of the transcripts was undertaken by researchers independent 145 of the pharmacy department (SC, ET). Confirmability was established by through peer debriefing sessions as 146 discussed above. 147 148

Administrative activity data consults were conducted (Table 1) . Of these, 13,543 (83%) were provided in-person, 2,608 (16%) were 152 provided by telephone and 226 (1.4%) by video consults. In the 9-months preceding the COVID-19 restrictions 153

in Brisbane, Australia (June 2019 to February 2020) the total number of consults (7626) provided by the 154 service did not differ greatly from the 9-months after the restrictions (7,760 consults conducted between 155

April 2020 -December 2020), however, the modality of care by which these consults were deliver changed. 156

There were approximately 950 in-person consults in February 2020, dropping to about 500 in April 2020. 157

[Include Table 1 Multiple clinics had to stop completely or pause for a period of time. These service interruptions were due 166

to the vulnerability of their patient cohort, if exposed to COVID-19, or cancellations of non-urgent care within 167 the hospital (e.g. elective surgery). Care that was categorised as urgent such acute orthopaedic assessment 168 and treatment continued in-person with social distancing restrictions. Telephone activity was two-fold higher 169

in March than February, and more than four-times higher in April, gradually reducing over time as in-person 170 services resumed. While video consults have increased from approximately 4 monthly consultations prior to 171

March 2020, to approximately 20 monthly consultations between April to December, they only make up a 172 very small proportion of total consultations ( Figure 1 ). 173 Of the 34 staff interviewed, 68% were female, 74% were aged 31-50 years and the cohort was comprised of: 178 16 outpatient pharmacists, 9 pharmacist team leaders, 5 nurses (clinical nurse, diabetes specialised, 179 telehealth navigator) and 4 doctors (specialist consultants and registrars) ( Table 3 ). The interviewees 180

represented the 18 outpatient clinics who added a pharmacist to their team in mid-2019. 181 182 [Include Table 3 here] 183

Two overall themes were identified and included: 1) COVID-19 -the sudden disruptor, and 2) influences on 184 choice of telehealth modality. These themes along with their nine categories are listed in Figure 2 and 185 described in detail below with exemplars. 186

Include Figure 2 here 187 COVID-19 -the sudden disruptor 188 189

In some clinics, because of the urgency to provide alternative ways for in-person care, new workflows had to 191 be developed often resulting in an increased workload. While many consultations were made at a distance, 192 when a patient was acutely unwell and needed an in-person consultation, a COVID-safe clinic was set up. A 193 triage process (determined by management) was adopted to assess which patients would come in-person to 194 the clinic depending on the severity and risk of each case, keeping chronic and stable patients for phone 195 reviews. Some pharmacists modified their roles, reducing their clinics to an ad hoc basis (i.e. only when 196 requested) so they had capacity to support elsewhere across the hospital service when needed. 197

Decisions to offer telephone reviews meant that in some instances the pre-COVID access to multidisciplinary 198 team (MDT) assessments were removed. In this model, phone reviews were only completed by the doctors; 199 pharmacist and nurses were no longer part of the consultation. Other clinics tried to maintain patient-clinician contact with all the MDT, however, this created administrative 204 challenges. From an administrative perspective, the shift to phone consults made it difficult to schedule MDT 205 appointments. During in-person clinics, the patient either meets with the whole MDT at once or moves from 206 one room to another seeing a different clinician. During phone appointments, however, this patient flow is 207 disrupted, and if one clinician is delayed, the next cannot connect with the patient or the patient cannot 208 determine which clinician they are consulting with at the time. Correlating with the administrative activity data, interviewees described a sudden decrease in patient 217 numbers for in-person visits during the peak COVID-19 restrictions. Even after COVID-19 restrictions were 218 relaxed in Queensland (May 2020), several clinics continued with telephone and video consult modalities of 219 care, according to patients' needs and the specificity of each clinic. These modalities enabled care 220 commensurate with physical distancing requirements and the limited physical spaces in the hospital's waiting 221

rooms. An approach wherein one in every three consults would be in-person, and the other two would be 222 performed by video or telephone, was one of the strategies adopted to cope with social distancing and 223 decrease the number of patients coming for in-person consultations. 224

Another model adopted by some chronic conditions' specialities, such as oncology and haematology, was to 225 offer monthly phone consults for patient reviews, followed by couriered medication for oral therapies. This 226 model appeared to be appealing and convenient for patients. However, one interviewee emphasised that for 227 that model to be sustainable, it must provide both a financial benefit for the health system, as well as benefit 228

for the patients. After the experience with this model, one interviewee feared that some patients might resist 229 returning to in-person care; a concept they appeared resistant too due to the financial costs. 230

Participant 27 -And as soon as they have to start coming into the hospital once a month, they ' knowledge and the ability to perform a video consult was also mentioned as an enabler. 277

Participant 4 -So it was just a matter of getting the patient on board to kind of figure out how to do stuff. 278

On the other hand, the lack of infrastructure and skilled workforce were also quoted as barriers by other 279 clinic pharmacists. Interviewees highlighted the importance of using the required hospital-endorsed platform 280

to virtually connect with their patients, to ensure high levels of data security and privacy. However, some 281

interviewees discussed struggling to use the hospital-endorsed platform. They also indicate the lack of 282 adequate technical support and logistic hurdles as impeditive to shift to video consults. For those clinics who 283 preferred in situ telehealth, rather than using the PAH telehealth centre (purpose-built telehealth rooms at 284 the basement of the hospital), there were, at times difficulties finding an appropriate space within the clinic 285

to conduct video consults. Also, lack of infrastructure on the other end, either the patients lack of resources, 286 devices or limited facilities infrastructure in prison settings were also reported to hinder the adoption of 287 video consults. initial adequate support to make video consults part of an efficient routine, it would take more time and 292

energy. There was a perception that video consults would take a lot longer to set up than phone consultations 293

and was therefore not appropriate in time-critical consults. For example, in the outpatient preadmission 294 clinic, patients needed reviews before scheduled surgeries. In the example below, the interviewee cited the 295 need to wait for three days before being able to set up a teleconference. 296 

Conversely, interviewees described phone consults as their main modality choice when they needed to 301 conduct consults virtually, as it was perceived to be easy and ready to use. 302 

One of the factors described as favourable to the rapid shift to phone consults instead of video is the ability 305 to access medical records via integrated electronic medical records (ieMR). Before the widespread adoption 306 of ieMR, video consults were more advantageous than phone consults as an effective and secure way for the 307 pharmacist to confirm the patient's prescribed medication. The patient could display their medicine on 308 screen and tell how they were taking it. The access to up-to-date medicine information on ieMR has 309 withdrawn this advantage. One pharmacist mentioned that: 310 Participant 14 -I think eHealth records is making a huge difference in terms of how we carry out phone reviews. Video consults are better but more challenging to implement than phone consults. Nothing is as good 323 as in-person.

The overall opinions about different modalities of care differed. However, there did appear to be a 325 developing hierarchy of effectiveness. Interviewees ranked video consults as more effective and sustainable 326 than phone consults, but not as good as in-person consult (Figure 3) . Although it was recognised that phone 327 consults were a reasonable alternative to decrease potential exposure to COVID-19, interviewees described 328 their limitations. For instance, the inability to visualise the patient, read their body language, and the 329 increased difficulty to build rapport over the phone deemed phone calls as less effective than in-person 330

consults. 331

We need to see the patient. Video link would have been a lot more sustainable.

Interviewees also recognise the benefits when patients can observe their health care professional. 334

Interviewees cited the importance of visual cues to establish a trustful relationship. Conversely, there is an 335

implication that potential detachment in phone consultations make it easier for clients to end the call in a 336 shorter amount of time. 

Further, interviewees described the difficulty of connecting with their patients for phone consults, even when 344 consults were pre-booked or scheduled in advance patients would not always answer or be free to talk. 345

Additional patient-end challenges reported included patient hearing or communication difficulties, mental 346 and cognitive impairments and those who spoke English as a second language and required an interpreter. 347

Despite these limitations of phone consults, they continued to be used at a much higher rate that video 348

consults. The reason for this appeared to be largely due to the issues with implementation and ease of use. 349

According to some interviewees, phone consults were more efficient, familiar, and easier than video consults. 350 technology. In one of the endocrinology clinics, for example, patients were already using blood glucose 361 readers and interacting with their health care professionals using an app before the COVID-19 pandemic. 362

Consequently, for those patients the transition to follow-up video consults was smoother than other patients. 363

Also, patients and professionals' acceptability of video consults was attributed to the increased familiarity 364 with video consults, resulting from the COVID-19 social distancing requirements. 365

The lack of technical onboarding support services to assist patients to setup a video consults, together with 366 patient-end challenges with troubleshooting, was also mentioned as a barrier to adopting video consults. 367

Queensland Health's website provides informative materials and direct line to support patients. However, 368

often the technical support during the first contact using video remained with the health care professional, 369

which adds an extra burden on them. 370 

Some clinicians stated that their patients had tried to use video consults and struggled, so they prefer to talk 389 over the phone. Also, interviewees asserted that some patients do not have their own digital devices, enough 390 data available and/or good connectivity to connect via video, and therefore they would still need to travel to 391 use equipped facilities able to perform video consults, such as their local hospital or general practitioner. 392 393

We investigated how telehealth was used in a metropolitan outpatient pharmacy setting before, during and 395 after peak COVID-19 restrictions and the various influences on the uptake of phone and video modalities. In 396 this setting, multiple factors were in place to support the use of video consults including the provision of 397 technology, managerial support, and financial incentives that favoured the use of video over telephone. 398

COVID-19 could have been the 'perfect storm' to accelerate video consult activity. Instead, what occurred 399 was a rapid switch to the telephone and very limited use of video. The activity data demonstrates that as 400 soon as COVID-19 restrictions eased, clinicians gradually returned to in-person appointments, maintaining 401 some use of phone consults and very limited use of video consults. Australian data on other health 402 professionals such as general practitioners also demonstrates a quick transition to telephone during the 403 COVID-19 pandemic and limited uptake of video consults. 7 Few studies, however, have begun to understand 404 why this occurred and the various influences impacting upon clinicians' decisions. This study elucidates some 405 of the perceived clinician and broader contextual challenges that led to the limited uptake of video consults 406

including the additional administrative and planning work required, perceptions that patients were unable 407 to use the technology, and the belief that in-person care was 'better'. 408

Broader organisational influences to use telehealth appear to have a limited impact if clinicians are resistant 409 or reluctant to use it. This phenomenon has previously been highlighted by Wade et al. 15, 16 A lack of clinician 410 willingness can be further exacerbated by poor experiences with telehealth 6,17 which reportedly occurred 411 during the COVID-19 period given the rapid and unplanned transition. Fundamental to changing a clinician's 412 behaviour and way of working must be a belief that the new way of working will provide additional benefit. 413

Discussed another way by Abimbola et al., 18 is that the benefit of telehealth must outweigh the 'transaction 414

cost' (i.e. the effort, time and costs required to complete a clinical interaction). This likely explains to some 415 degree why telephone was so heavily favoured; the transaction cost was lower. Therefore, to increase use of 416 video consults the process of delivering care remotely needs to be easier (e.g. simple for clinicians and 417 patients to use, available technology, good connection and audio-visual quality) and the benefits made more 418 obvious (e.g. improved care processes, patient satisfaction, improved access to patients and/or clinical 419 outcomes). The best way of achieving this is likely though cooperative, participatory approaches that engage 420

and work with clinicians, consumers, and administrators to determine where the telehealth value proposition 421

lies. 19 To get the most benefit out of these models of care, the designed digital solution (and workflows of 422 use) should meet the needs of its intended users. 20 423

The perceived relative advantage of telehealth differed between interviewees. Some pharmacists felt that 424 telehealth offers opportunities to connect early with outpatient pharmacy patients and triage those at risk 425 of medication errors and readmission. There were instances where clinicians persisted with using video 426 consults even when the technology and infrastructure did not enable smooth experiences. These tended to 427 be where clinicians who perceived that the patient benefit would be high, and this benefit outweighed the 428 additional effort required by the clinician. Examples included the preadmission clinic, mental health, and the 429 diabetes clinics. 430

Reasons for different levels of uptake within the literature include different visions, skills, fears, and 431 opportunities and influenced by diversity of intentions to collaborate, solve problems, and improve 432 efficiencies. 21 In our study, the motivation of the clinician appeared to be strongly influenced by experiences 433 of success and improved efficiencies (e.g. ensuring a patient being transferred from a correctional facility to 434 hospital for surgery was well-prepared and necessary medications had been stopped avoiding a failed surgery 435 and costly transfer). Further, it appeared that some practitioners were more motivated by financial incentives 436 than others. Unsurprisingly, those in managerial positions that were required to directly report on activity 437

numbers appeared more aware of the financial effects of activity, but this did not necessarily result in 438 additional video consults (which attracted greater funding than phone). Previous studies have also identified 439 a disconnect between policy pressures and actual use video consults. 22 440

The clinicians described how in their experience video consults led to new workflows and at times additional 441 workload. They described issues with technology and this experience led to a belief that telehealth was less 442 efficient than in-person care. There was also a reported increased in the administrative workload related to 443

planning and supporting telehealth. The literature also supports that the use of both phone and video 444 consults can increase workload. 6,23 Additionally, since offering video consults was new for most pharmacists, 445

learning the location of resources and infrastructure while providing ongoing care posed a challenge. These 446 barriers did not exist in the same way for phone consults. In some instances, new ways of reorganising the 447 service resulted in unintended consequences such as the exclusion of pharmacist from MDT appointments 448 which were swapped to doctor-patient phone consults. The exclusion of the pharmacist from this patient 449 consultation may have limited the early identification of medication-related issues. While telephone was 450 described as easier to adopt, there was recognition that video consults would in many instances provide 451 enhanced information that may lead to a better clinical outcome. In-person care however, was viewed as the 452

'gold-standard' by many clinicians, aligned with other studies. 24 Implementation of video consults into busy 453 outpatient hospital settings has previously been described as complex and time-consuming; 25 the COVID-19 454 pandemic appeared to further exacerbate these challenges as the workflow and modality changes were 455 required near-immediately. 456

There was a strong assumption that patients would not be able to use the technology. Strategies to support 457 patients through the process (e.g. education, pre-testing, having a family member or support person) 458 appeared limited. Clinicians also did not report routinely checking patients access and confidence to using 459 technology prior to determining the modality of care of the appointment. Rather, clinicians assumed 460 accessing a video consult would be too difficult for older patients or for those with particular health 461 conditions (e.g. cognitive impairment or mental health varying levels of support were needed for patients to transition to video depending on how familiar they 485

were with technology, pharmacists discussed how patient capabilities were more assumed than known. In-486 person clinics are perceived as the best option for many clinicians and as physical distancing restrictions ease, 487

clinicians are likely to gradually return to in-person modalities. Future studies should focus on quantifying 488 patient benefits such as attendance rates between phone, video and in-person. Additionally, implementation 489 studies are required to co-develop solutions to embed telehealth options into outpatient pharmacy settings 490 that provide the best experience for both patients and clinicians. 491 492 J o u r n a l P r e -p r o o f • The funding model incentive • Pressure to meet activity targets • Perceived incentives to the rapid adoption of phone consults • Infrastructure and skilled workforce influences to adopt video consults • Video consult is not routine and therefore inefficiencies remain • Patient's support and familiarity with the technology • Video consults are better but more challenging to implement than phone consults.

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We would like to thank Monica Taylor for her assistance with conducting the interviews and for the Princess Alexandra Hospital Decision Support Unit who provided activity data.