scholarly journals Implementing online consultations in primary care: a mixed-method evaluation extending normalisation process theory through service co-production

BMJ Open ◽  
2018 ◽  
Vol 8 (3) ◽  
pp. e019966 ◽  
Author(s):  
Michelle Farr ◽  
Jonathan Banks ◽  
Hannah B Edwards ◽  
Kate Northstone ◽  
Elly Bernard ◽  
...  
Keyword(s):  
Primary Care ◽  
Mixed Method ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Free Text ◽  
Method Evaluation ◽  
Current Form ◽  
Financial Investment ◽  
Face To Face ◽  
Consultation System

ObjectivesTo examine patient and staff views, experiences and acceptability of a UK primary care online consultation system and ask how the system and its implementation may be improved.DesignMixed-method evaluation of a primary care e-consultation system.SettingPrimary care practices in South West England.MethodsQualitative interviews with 23 practice staff in six practices. Patient survey data for 756 e-consultations from 36 practices, with free-text survey comments from 512 patients, were analysed thematically. Anonymised patients’ records were abstracted for 485 e-consultations from eight practices, including consultation types and outcomes. Descriptive statistics were used to analyse quantitative data. Analysis of implementation and the usage of the e-consultation system were informed by: (1) normalisation process theory, (2) a framework that illustrates how e-consultations were co-produced and (3) patients’ and staff touchpoints.ResultsWe found different expectations between patients and staff on how to use e-consultations ‘appropriately’. While some patients used the system to try and save time for themselves and their general practitioners (GPs), some used e-consultations when they could not get a timely face-to-face appointment. Most e-consultations resulted in either follow-on phone (32%) or face-to-face appointments (38%) and GPs felt that this duplicated their workload. Patient satisfaction of the system was high, but a minority were dissatisfied with practice communication about their e-consultation.ConclusionsWhere both patients and staff interact with technology, it is in effect ‘co-implemented’. How patients used e-consultations impacted on practice staff’s experiences and appraisal of the system. Overall, the e-consultation system studied could improve access for some patients, but in its current form, it was not perceived by practices as creating sufficient efficiencies to warrant financial investment. We illustrate how this e-consultation system and its implementation can be improved, through mapping the co-production of e-consultations through touchpoints.

scholarly journals Use of an electronic consultation system in primary care: a qualitative interview study

2017 ◽  
Vol 68 (666) ◽  
pp. e1-e8 ◽  
Author(s):  
Jon Banks ◽  
Michelle Farr ◽  
Chris Salisbury ◽  
Elly Bernard ◽  
Kate Northstone ◽  
...  
Keyword(s):  
Primary Care ◽  
Clinical Decision Making ◽  
Qualitative Interview ◽  
Interview Study ◽  
Sufficient Information ◽  
Current Form ◽  
Financial Investment ◽  
Consultation System ◽  
Qualitative Interview Study ◽  
General Practices

BackgroundThe level of demand on primary care continues to increase. Electronic or e-consultations enable patients to consult their GP online and have been promoted as having potential to improve access and efficiency.AimTo evaluate whether an e-consultation system improves the ability of practice staff to manage workload and access.Design and settingA qualitative interview study in general practices in the West of England that piloted an e-consultation system for 15 months during 2015 and 2016.MethodPractices were purposefully sampled by location and level of e-consultation use. Clinical, administrative, and management staff were recruited at each practice. Interviews were transcribed and analysed thematically.ResultsTwenty-three interviews were carried out across six general practices. Routine e-consultations offered benefits for the practice because they could be completed without direct contact between GP and patient. However, most e-consultations resulted in GPs needing to follow up with a telephone or face-to-face appointment because the e-consultation did not contain sufficient information to inform clinical decision making. This was perceived as adding to the workload and providing some patients with an alternative route into the appointment system. Although this was seen as offering some patient benefit, there appeared to be fewer benefits for the practices.ConclusionThe experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system. The study also highlights the challenges of remote consultations, which lack the facility for real time interactions.

Benefits and Challenges of Using Virtual Primary Care During the COVID-19 Pandemic: An International Cross-sectional Survey Study (Preprint)

2021 ◽  
Author(s):  
Edmond Li ◽  
Rosy Tsopra ◽  
Geronimo Jimenez ◽  
Alice Serafini ◽  
Gustavo Gusso ◽  
...  
Keyword(s):  
Primary Care ◽  
Care Delivery ◽  
Lessons Learned ◽  
Survey Study ◽  
Free Text ◽  
Cross Sectional Survey ◽  
Online Questionnaire ◽  
Cross Sectional ◽  
Face To Face ◽  
Remote Care

BACKGROUND With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. OBJECTIVE We explored GPs’ perspectives on the main benefits and challenges of using digital remote care. METHODS GPs across 20 countries completed an online questionnaire between June – September 2020. GPs’ perceptions on main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. RESULTS A total of 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and accompanying legal frameworks. Main challenges included patient’s preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital remote care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. CONCLUSIONS At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how during the pandemic. Lessons learned can be used to inform the adoption of improved virtual care solutions, and support the long-term development of platforms that are more technologically robust, secure. INTERNATIONAL REGISTERED REPORT RR2-10.2196/30099

scholarly journals Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings

2019 ◽  
Vol 26 (1) ◽  
pp. e100088
Author(s):  
Rebecca G Mishuris ◽  
Joseph Palmisano ◽  
Lauren McCullagh ◽  
Rachel Hess ◽  
David A Feldstein ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Clinical Decision ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Implementation Barriers ◽  
Clinical Workflow ◽  
Primary Care Settings ◽  
Registration Number

BackgroundEffective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of ‘work’ necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and ‘work’ of implementation of two clinical decision support (CDS) tools across diverse care settings.MethodsWe conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions’ primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time.ResultsThe median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers’ participation domain (p=0.003), and all domains for medical directors (p<0.003) declined. At 6 months, the action domain decreased among Utah respondents (p=0.03), and all domains decreased among Wisconsin respondents (p≤0.008).ConclusionsThis study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies.Trial registration numberNCT02534987.

scholarly journals Correction: Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

PLoS ONE ◽  
2017 ◽  
Vol 12 (7) ◽  
pp. e0181893 ◽  
Author(s):  
Pauline O’Reilly ◽  
Siew Hwa Lee ◽  
Madeleine O’Sullivan ◽  
Walter Cullen ◽  
Catriona Kennedy ◽  
...  
Keyword(s):  
Primary Care ◽  
Interdisciplinary Team ◽  
Integrative Review ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Team Working ◽  
Facilitators And Barriers

scholarly journals Exploring the scope for Normalisation Process Theory to help evaluate and understand the processes involved when scaling up integrated models of care: a case study of the scaling up of the Gnosall memory service

2020 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Michael Clark ◽  
David Jolley ◽  
Susan Mary Benbow ◽  
Nicola Greaves ◽  
Ian Greaves
Keyword(s):  
Primary Care ◽  
Scale Up ◽  
Scaling Up ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Small Scale ◽  
Content Type ◽  
Service Models ◽  
Integrated Service

PurposeThe scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT).Design/methodology/approachThe article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project.FindingsNPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future.Research limitations/implicationsThe research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies.Practical implicationsNPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up.Social implicationsNPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up.Originality/valueThis paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models.

scholarly journals Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England

BMJ Open ◽  
2017 ◽  
Vol 7 (11) ◽  
pp. e016901 ◽  
Author(s):  
Hannah B Edwards ◽  
Elsa Marques ◽  
William Hollingworth ◽  
Jeremy Horwood ◽  
Michelle Farr ◽  
...  
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Waiting Times ◽  
Telephone Consultation ◽  
Face To Face ◽  
Online Consultation ◽  
South West ◽  
Consultation System ◽  
General Practices ◽  
South West England

ObjectivesEvaluation of a pilot study of an online consultation system in primary care. We describe who used the system, when and why, and the National Health Service costs associated with its use.Design15-month observational study.SettingPrimary care practices in South West England.Results36 General practices covering 396 828 patients took part in the pilot. The online consultation website was viewed 35 981 times over the pilot period (mean 9.11 visits per 1000 patients per month). 7472 patients went on to complete an ‘e-consultation’ (mean 2.00 online consultations per 1000 patients per month). E-consultations were mainly performed on weekdays and during normal working hours. Patient records (n=485) were abstracted for eight practices and showed that women were more likely to use e-consultations than men (64.7% vs 35.3%) and users had a median age of 39 years (IQR 30–50). The most common reason for an e-consultation was an administrative request (eg, test results, letters and repeat prescriptions (22.5%)) followed by infections/immunological issues (14.4%). The majority of patients (65.2%) received a response within 2 days. The most common outcome was a face-to-face (38%) or telephone consultation (32%). The former were more often needed for patients consulting about new conditions (OR 1.56, 95% CI 1.05 to 2.27, p=0.049). The average cost of a practice’s response to an e-consultation was £36.28, primarily triage time and resulting face-to-face/telephone consultations needed.ConclusionsUse of e-consultations is very low, particularly at weekends. Unless this can be improved, any impact on staff workload and patient waiting times is likely to be negligible. It is possible that use of e-consultations increases primary care workload and costs. Online consultation systems could be developed to improve efficiency both for staff and patients. These findings have implications for software developers as well as primary care services and policy-makers who are considering investing in online consultation systems.

scholarly journals Patients’ views on interactions with practitioners for type 2 diabetes: a longitudinal qualitative study in primary care over 10 years

2017 ◽  
Vol 68 (666) ◽  
pp. e36-e43 ◽  
Author(s):  
Hajira Dambha-Miller ◽  
Barbora Silarova ◽  
Greg Irving ◽  
Ann Louise Kinmonth ◽  
Simon J Griffin
Keyword(s):  
Type 2 Diabetes ◽  
Primary Care ◽  
Descriptive Analysis ◽  
Free Text ◽  
Individual Level ◽  
Face To Face ◽  
Relational Continuity ◽  
Over Time

BackgroundIt has been suggested that interactions between patients and practitioners in primary care have the potential to delay progression of complications in type 2 diabetes. However, as primary care faces greater pressures, patient experiences of patient–practitioner interactions might be changing.AimTo explore the views of patients with type 2 diabetes on factors that are of significance to them in patient–practitioner interactions in primary care after diagnosis, and over the last 10 years of living with the disease.Design and settingA longitudinal qualitative analysis over 10 years in UK primary care.MethodThe study was part of a qualitative and quantitative examination of patient experience within the existing ADDITION-Cambridge and ADDITION-Plus trials from 2002 to 2016. The researchers conducted a qualitative descriptive analysis of free-text comments to an open-ended question within the CARE measure questionnaire at 1 and 10 years after diagnosis with diabetes. Data were analysed cross-sectionally at each time point, and at an individual level moving both backwards and forwards between time points to describe emergent topics.ResultsAt the 1-year follow-up, 311 out of 1106 (28%) participants had commented; 101 out of 380 (27%) participants commented at 10-year follow-up; and 46 participants commented at both times. Comments on preferences for face-to-face contact, more time with practitioners, and relational continuity of care were more common over time.ConclusionThis study highlights issues related to the wider context of interactions between patients and practitioners in the healthcare system over the last 10 years since diagnosis. Paradoxically, these same aspects of care that are valued over time from diagnosis are also increasingly unprotected in UK primary care.

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