Building Compassionate Experience Through Compassionate Action: Qualitative Behavioral Analysis.

BACKGROUND: The acceleration of technology-based primary care during the COVID-19 pandemic outpaced the ability to understand whether and how it impacts care delivery and outcomes. As technology-based care continues to evolve, focusing on the core construct of compassion in a primary care context will help ensure high-quality patient care and increased patient autonomy and satisfaction. The ability to successfully operationalize the use of technology in patient-clinician interactions hinges on understanding not only how compassionate care is experienced in this context but also how clinicians can create it. OBJECTIVE: The objectives of this study were to understand whether and how compassionate behaviors are experienced in technology-based primary care interactions and identify the individual and contextual drivers that influence whether and how these behaviors occur. METHODS: We conducted a series of qualitative one-on-one interviews with primary care physicians, nurses, and patients. Qualitative data were initially analyzed using an inductive thematic analysis approach to identify preliminary themes for each participant group independently. We then looked across participant groups to identify areas of alignment and distinction. Descriptions of key behaviors that participants identified as elements of a compassionate interaction and descriptions of key drivers of these behaviors were inductively coded and defined at this stage. RESULTS: A total of 74 interviews were conducted with 40 patients, 20 nurses, and 14 primary care physicians. Key behaviors that amplified the experience of compassion included asking the patient's modality preference, using video to establish technology-based presence, sharing the screen, and practicing effective communication. Participants' knowledge or skills as well as their beliefs and emotions influenced whether or not these behaviors occurred. Contextual elements beyond participants' control influenced technology-based interactions, including resource access, funding structures, culture, regulatory standards, work structure, societal influence, and patient characteristics and needs. A high-yield, evidence-based approach to address the identified drivers of compassion-focused clinician behavior includes a combination of education, training, and enablement. CONCLUSIONS: Much of the patient experience is influenced by clinician behavior; however, clinicians need a supportive system and adequate supports to evolve new ways of working to create the experience of compassionate care. The current state of technology-based care operationalization has led to widespread burnout, societal pressure, and shifting expectations of both clinicians and the health system more broadly, threatening the ability to deliver compassionate care. For clinicians to exhibit compassionate behaviors, they need more than just adequate supports; they also need to receive compassion from and experience the humanity of their patients.

Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis.

BACKGROUND: Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use. OBJECTIVE: The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit. METHODS: This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use. RESULTS: Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups. CONCLUSIONS: Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.

Hospital-based ambulatory clinic adoption of video and telephone visits before and during the COVID-19 pandemic: a convergent mixed-methods study

Purpose: The purpose of this study is to understand virtual care use (e.g. telephone and video visits) during the COVID-19 pandemic across three hospital-based ambulatory clinics (i.e. mental health, renal and respiratory care) and to describe associated patient and provider experiences. Design/methodology/approach: A mixed-methods convergent study was conducted including quantitative electronic medical records data on virtual care use, electronic surveys assessing domains of experience (e.g. satisfaction, acceptance and technology use) among patient and providers and semi-structured interviews exploring the associated barriers and facilitators of virtual care adoption. Findings: Virtual care adoption rates and relative modality use (telephone vs video) varied across specialty clinics. Mental health clinics) showed the greatest use of virtual care and greater use of video over telephone, as compared to renal and respiratory care, where telephone was used almost exclusively. Patients and providers reported an overall good satisfaction and acceptance of virtual care (60–72%) across clinics, but commonly observed barriers (technical problems, behavioral adaptations needed and inequity) persisted. Good value propositions, tech support and the presence of early adopters who can support others in workflow re-design and highlight value propositions of virtual care were listed as adoption facilitators. Originality/value: The study provides a unique opportunity to compare the rate of virtual care adoption before and during the COVID-19 pandemic across distinct specialties that operate within the same organizational and political setting. This study showed that the nature of the condition (e.g. mental health conditions) and the characteristics of the users (e.g. younger patients) may drive models of care with higher rate of video use. Focusing on removing common barriers, like providing tech support and ensuring equitable access to patients, continues to be important even in the context of high virtual care adoption rates during the pandemic.

Implementing a Virtual Emergency Department: Qualitative Study Using the Normalization Process Theory.

BACKGROUND: COVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care's potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal. OBJECTIVE: This study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations. METHODS: We conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT. RESULTS: A total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group. CONCLUSIONS: As further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient.

Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study.

BACKGROUND: Comprehensive multi-institutional patient portals that provide patients with web-based access to their data from across the health system have been shown to improve the provision of patient-centered and integrated care. However, several factors hinder the implementation of these portals. Although barriers and facilitators to patient portal adoption are well documented, there is a dearth of evidence examining how to effectively implement multi-institutional patient portals that transcend traditional boundaries and disparate systems. OBJECTIVE: This study aims to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology and to identify the lessons learned to guide the implementation of similar patient portal models. METHODS: This multimethod study included an analysis of quantitative and qualitative data collected during an evaluation of the multi-institutional MyChart patient portal that was deployed in Southwestern Ontario, Canada. Descriptive statistics were performed to understand the use patterns during the first 15 months of implementation (between August 2018 and October 2019). In addition, 42 qualitative semistructured interviews were conducted with 18 administrative stakeholders, 16 patients, 7 health care providers, and 1 informal caregiver to understand how the implementation approach influenced user experiences and to identify strategies for improvement. Qualitative data were analyzed using an inductive thematic analysis approach. RESULTS: Between August 2018 and October 2019, 15,271 registration emails were sent, with 67.01% (10,233/15,271) registered for an account across 38 health care sites. The median number of patients registered per site was 19, with considerable variation (range 1-2114). Of the total number of sites, 55% (21/38) had ≤30 registered patients, whereas only 2 sites had over 1000 registered patients. Interview participants perceived that the patient experience of the portal would have been improved by enhancing the data comprehensiveness of the technology. They also attributed the lack of enrollment to the absence of a broad rollout and marketing strategy across sites. Participants emphasized that provider engagement, change management support, and senior leadership endorsement were central to fostering uptake. Finally, many stated that regional alignment and policy support should have been sought to streamline implementation efforts across participating sites. CONCLUSIONS: Without proper management and planning, multi-institutional portals can suffer from minimal adoption. Data comprehensiveness is the foundational component of these portals and requires aligned policies and a key base of technology infrastructure across all participating sites. It is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment. It is also critical to establish a clear vision and ensure buy-ins from organizational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.

Identifying optimal frameworks to implement or evaluate digital health interventions: a scoping review protocol.

INTRODUCTION: Digital health interventions (DHIs) are defined as health services delivered electronically through formal or informal care. DHIs can range from electronic medical records used by providers to mobile health apps used by consumers. DHIs involve complex interactions between user, technology and the healthcare team, posing challenges for implementation and evaluation. Theoretical or interpretive frameworks are crucial in providing researchers guidance and clarity on implementation or evaluation approaches; however, there is a lack of standardisation on which frameworks to use in which contexts. Our goal is to conduct a scoping review to identify frameworks to guide the implementation or evaluation of DHIs. METHODS AND ANALYSIS: A scoping review will be conducted using methods outlined by the Joanna Briggs Institute reviewers' manual and will conform to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Studies will be included if they report on frameworks (ie, theoretical, interpretive, developmental) that are used to guide either implementation or evaluation of DHIs. Electronic databases, including MEDLINE, EMBASE, CINAHL and PsychINFO will be searched in addition to grey literature and reference lists of included studies. Citations and full text articles will be screened independently in Covidence after a reliability check among reviewers. We will use qualitative description to summarise findings and focus on how research objectives and type of DHIs are aligned with the frameworks used. ETHICS AND DISSEMINATION: We engaged an advisory panel of digital health knowledge users to provide input at strategic stages of the scoping review to enhance the relevance of findings and inform dissemination activities. Specifically, they will provide feedback on the eligibility criteria, data abstraction elements, interpretation of findings and assist in developing key messages for dissemination. This study does not require ethical review. Findings from review will support decision making when selecting appropriate frameworks to guide the implementation or evaluation of DHIs.

Closing the Virtual Gap in Health Care: A Series of Case Studies Illustrating the Impact of Embedding Evaluation Alongside System Initiatives.

Early decisions relating to the implementation of virtual care relied on necessity and clinical judgement, but there is a growing need for the generation of evidence to inform policy and practice designs. The need for stronger partnerships between researchers and decision-makers is well recognized, but how these partnerships can be structured and how research can be embedded alongside existing virtual care initiatives remain unclear. We present a series of case studies that illustrate how embedded research can inform policy decisions related to the implementation of virtual care, where decisions are either to (1) discontinue (red light), (2) redesign (yellow light), or (3) scale up existing initiatives (green light). Data were collected through document review and informal interviews with key study personnel. Case 1 involved an evaluation of a mobile diabetes platform that demonstrated a mismatch between the setting and the technology (decision outcome: discontinue). Case 2 involved an evaluation of a mental health support platform that suggested evidence-based modifications to the delivery model (decision outcome: redesign). Case 3 involved an evaluation of video visits that generated evidence to inform the ideal model of implementation at scale (decision outcome: scale up). In this paper, we highlight the characteristics of the partnership and the process that enabled success and use the cases to illustrate how these characteristics were operationalized. Structured communication included monthly check-ins and iterative report development. We also outline key characteristics of the partnership (ie, trust and shared purpose) and the process (ie, timeliness, tailored reporting, and adaptability) that drove the uptake of evidence in decision-making. Across each case, the evaluation was designed to address policy questions articulated by our partners. Furthermore, structured communication provided opportunities for knowledge mobilization. Structured communication was operationalized through monthly meetings as well as the delivery of interim and final reports. These case studies demonstrate the importance of partnering with health system decision-makers to generate and mobilize scientific evidence. Embedded research partnerships founded on a shared purpose of system service provided an effective strategy to bridge the oft-cited gap between science and policy. Structured communication provided a mechanism for collaborative problem-solving and real-time feedback, and it helped contextualize emerging insights.

Developing an explanatory theoretical model for engagement with a web-based mental health platform: results of a mixed methods study.

BACKGROUND: With the growing need for accessible, high-quality mental health services, especially during the COVID-19 pandemic, there has been increasing development and uptake of web-based interventions in the form of self-directed mental health platforms. The Big White Wall (BWW) is a web-based platform for people experiencing mental illness and addiction that offers a range of evidence-based self-directed treatment strategies. Drawing on existing data from a large-scale evaluation of the implementation of BWW in Ontario, Canada (which involved a pragmatic randomized controlled trail with an embedded qualitative process evaluation), we sought to investigate the influences on the extent to which people engage with BWW. METHODS: In this paper we drew on BWW trial participants' usage data (number of logins) and the qualitative data from the process evaluation that explored participants' experiences, engagement with and reactions to BWW. RESULTS: Our results showed that there were highly complex relationships between the influences that contributed to the level of engagement with BWW intervention. We found that a) how people expected to benefit from using a platform like BWW was an important indicator of their future usage, b) moderate perceived symptoms were linked with higher engagement; whereas fewer actual depressive symptoms predicted use and anxiety had a positive linear relationship with usage, and that c) usage depended on positive early experiences with the platform. CONCLUSIONS: Our findings suggest that the nature of engagement with platforms such as BWW is not easily predicted. We propose a theoretical framework for explaining the level of user engagement with BWW that might also be generalizable to other similar platforms.

Videoconferencing at home for psychotherapy in the postpartum period: Identifying drivers of successful engagement and important therapeutic conditions for meaningful use

Purpose Virtual care has almost become the norm since COVID-19 mandated social distancing. Prior, the use of personal videoconferencing was being explored as an appealing option to overcome barriers to care, but little was studied about how we should do it and for whom. This study aimed to answer these questions for women receiving psychotherapy in the postpartum period when there are significant barriers to attending office-based care. Methods Twelve postpartum women who had the option to attend their psychotherapy sessions for the treatment of mood and/or anxiety symptoms via videoconferencing over a 3-month time period were interviewed about their experience. The three therapists providing care were also interviewed early in adoption of the virtual treatment and at the end of the study. Thematic analysis was conducted to identify themes for the initial and ongoing engagement with videoconferencing, which were triangulated with therapist input. Findings Major themes which emerged related to (a) initial willingness to engage with videoconferencing, (b) technological compatibility, and (c) a good patient fit, with positive and negative influencers for each. Therapeutic considerations were identified, including (a) an initial in-person meeting when possible, (b) matching the therapy format to the clinical situation, (c) attention to the home environment, and (d) a clear therapy frame. Conclusions Therapists should consider that videoconferencing might not be appropriate for every patient;but in the right context and with appropriate therapeutic considerations, offering this treatment format may actually facilitate an individual's recovery. These findings can help to inform the future delivery of videoconferencing psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved)