Virtual Primary Care Research Articles

A cross-programme vertically integrated communication and professionalisation curriculum, adapted from pharmacy for nursing

The Clinical Communication Team at the University of Birmingham are undertaking an ambitious project where students across all healthcare programmes will interact within a single virtual healthcare community – ‘Wood Brooke’ – via simulation activities. The vertical nature of the programme means students can ‘follow’ the illness/life journeys of a series of families that they meet early in the course over a 3–4 year timeframe. Additionally, they can meet and interact with simulated healthcare professionals working in Wood Brooke’s virtual primary, community, and secondary care facilities. Wood Brooke is already well-established throughout our 4-year Pharmacy degree, being integrated into teaching and testing not just for communication, but linked to other clinical aspects of the Programme. We will share our model, and experiences, successes, and challenges. Recently Wood Brooke was adapted for Birmingham’s 3-year BNurs programme as a vertically integrated clinical communication/professionalisation strand. It is well documented that nursing students should be trained in patient-centred communication [1]. Students from Adult, Child, and Mental Health Nursing mix in the sessions for intra-professional learning and breadth of peer support and feedback. Sessions in Year 1 focus on cases relating to three families from Wood Brooke from patient and relative/carer perspectives. Year 2 builds on the simulation to consider intra and interprofessional colleague interactions in community-based and acute settings through telephone and face to face role play simulation. This builds on the 3 family cases introduced in the first year, introducing other members within the family. Year 3 is under development. Feedback from learners about the Programme has been positive. This is not a research project so we will not be presenting ‘data’. A result in progress is rolling Wood Brooke out to other Programmes, including Medicine and Dentistry, as part of curriculum review. Discussion may focus on the potential benefits of healthcare students having shared visibility of patient narratives/experiences where that patient is accessing care under more than one service. Inclusivity and designing a ‘community’ reflective of the population has been central. The vertical development of patient narratives over several years enables adaption of the programme to meet new priorities and needs (including, e.g., shift to remote working for COVID-19, and evolving patient demographics). 1. Gutiérrez-Puertas L, Márquez-Hernández VV, Gutiérrez-Puertas V, Granados-Gámez G, Aguilera-Manrique G. Educational interventions for nursing students to develop communication skills with patients: a systematic review. International journal of environmental research and public health. 2020;17(7):2241.

Health Care Use Prior to Diabetes Diagnosis in Children Before and During COVID.

During COVID-19, healthcare systems reorganized with less ambulatory care and a shift to virtual care (1). There was an increase in diabetic ketoacidosis (DKA), a preventable, life-threatening condition, at diabetes onset in children during COVID-19 (2). DKA at diabetes onset has been attributed to delays in seeking care, missed diagnosis or delays in referral following a primary healthcare contact (3). Reasons for the recent increase in DKA may relate to hesitancy to seek care, providers failing to recognize diabetes symptoms due to cognitive bias focusing on COVID-19, or limitations of virtual care. To explore these potential mechanisms, we compared in-person and virtual primary care and emergency department (ED) visits in children four weeks prior to diagnosis, before and during COVID-19. If increased DKA rates during COVID-19 were due to more missed diagnoses, possibly related to virtual visits, children with DKA would be more likely to have visits during vs. pre-COVID-19. If families were hesitant to seek or unable to access care during COVID-19, then among those with no visits, there would be a higher proportion with DKA.

Advancing virtual primary care for people with opioid use disorder (VPC OUD): a mixed-methods study protocol

IntroductionThe emergence of COVID-19 introduced a dual public health emergency in British Columbia, which was already in the fourth year of its opioid-related overdose crisis. The public health response to...

Accessibility of Virtual Primary Care for Adults With Intellectual and Developmental Disabilities During the COVID-19 Pandemic: Qualitative Study.

BackgroundThe COVID-19 pandemic has led to an unprecedented increase in the delivery of virtual primary care. Adults with intellectual and developmental disabilities (IDDs) have complex health care needs, and little is known about the value and appropriateness of virtual care for this patient population.ObjectiveThe aim of this study was to explore the accessibility of virtual primary care for patients with IDDs during the pandemic.MethodsWe conducted semistructured interviews with 38 participants in Ontario, Canada between March and November 2021. A maximum variation sampling strategy was used to achieve a diverse sample including 11 adults with IDDs, 13 family caregivers, 5 IDD support staff members, and 9 primary care physicians. An iterative mixed inductive and deductive thematic analysis approach was used to code the data and synthesize higher-level themes. The analysis was informed by the Levesque Patient-Centered Access to Health Care Framework.ResultsWe identified themes related to 4 of 5 access-to-care dimensions that highlighted both the benefits and challenges of virtual care for adults with IDDs. The benefits included saving time spent traveling and waiting; avoiding anxiety and challenging behavior for patients who struggle to attend in-person visits; allowing caregivers who live far away from their loved ones to participate; reducing illness transmission; and allowing health care providers to see patients in their home environments. The challenges included lack of access to necessary technology, lack of comfort or skill using technology, and lack of nonverbal communication; difficulty engaging and establishing rapport; patient exclusion from the health care encounter; and concerns about privacy and confidentiality. An overarching theme was that “one size does not fit all,” and the accessibility of virtual care was dependent on the interaction between the following 5 categories of factors: patient characteristics, patient context, caregiver characteristics, service context, and reason for a particular primary care visit. Though virtual care was not always appropriate, in some cases, it dramatically improved patients’ abilities to access necessary health care.ConclusionsThis study suggests that a flexible patient-centered system including multiple delivery modalities is needed to ensure all patients have access to primary care. Implementing this system will require improved virtual care platforms, access to technology for patients and caregivers, training for primary care providers, and appropriately aligned primary care funding models.

Examining virtual visit use during a pandemic and perspectives of primary care providers, patients and caregivers: a mixed-methods research protocol

IntroductionCOVID-19 prompted rapid shifts to virtual primary care; however, the secondary implications and ideal applications of this change require further consideration. Patient and public stakeholder input has been bypassed. To...

Virtual Primary Care Implementation During COVID-19 in High-Income Countries: A Scoping Review.

Background: The purpose of this scoping review was to map the challenges, strategies, and lessons learned from high-income countries that can be mobilized to inform decision-makers on how to best implement virtual primary care services during and after the COVID-19 pandemic. Findings of our scoping review identified the barriers and strategies within the Quadruple Aim components, which may prove to be an effective implementation strategy for virtual care adoption in primary care settings. Materials and Methods:The two concepts of virtual care and COVID-19 were searched in MEDLINE, EMBASE, and CINAHL on August 10, 2020, and Scopus was searched on August 15, 2020. The database searches returned 10,549 citations and an additional 766 citations were retrieved from searching the citations from the reference lists of articles that met all inclusion criteria. A total of 1,260 full-text articles were reviewed of which 38 articles met the eligibility criteria for inclusion in the review. Results: Seven key barriers and strategies were identified for the implementation of virtual primary care. Of the 38 articles included, the key barriers identified were equitable access to care (n = 20; 53%), lack of funding for virtual care (n = 14; 37%), negative patient and clinician perception (n = 11, 29%), lack of regulatory policies (n = 10, 26%), inadequate clinical workflows (n = 9, 21), lack of virtual care infrastructure (n = 8, 21%), and insufficient virtual care training and education (n = 5, 13%). Strategies included the following: increased funding (n = 15, 39%), improving clinical workflows (n = 13, 34%), appropriate education and training (n = 11, 29%), improving virtual care infrastructure and patient equity (n = 7, 18%), establishing regulatory policies (n = 5, 13%), and improving patient and clinician perceptions (n = 3, 7%). Conclusions: As many countries enter potential subsequent waves of the COVID-19 pandemic, applying early lessons learned to mitigate implementation barriers can help with the transition to equitable and appropriate virtual primary care services.

Virtual care and the influence of a pandemic: Necessary policy shifts to drive digital innovation in healthcare.

The potential for virtual healthcare to improve access to primary care services in Canada has long been a topic of discussion; however, implementation has been slow despite growing interest among the public. Non-essential service lockdowns implemented in 2020 in response to the COVID-19 pandemic catalyzed rapid and widespread uptake of virtual healthcare delivery. It is important to consider how to maintain equitable access to virtual care following the pandemic. We conducted a narrative scoping review to understand barriers related to the sustained adoption of virtual primary care delivery in Canada. Barriers at the system, healthcare provider, and patient levels were related to digital health infrastructure, and the regulatory environment governing virtual care provision and remuneration for healthcare professionals. The article identifies areas where policy shifts by health system leaders could sustain the longer-term availability of Canadian virtual care services.

Assessing the Quality of Direct-to-Consumer Teleconsultation Services in Canada.

The objective of this study was to describe and assess the quality of the direct-to-consumer medical teleconsultation landscape in three Canadian provinces. An environmental scan of primary care teleconsultation platforms was conducted in January 2022 to identify medical teleconsultation platforms in Quebec (Qc), Ontario, and British Columbia (BC). The quality of each teleconsultation platform was assessed using a modified version of the HONcode principles. Nineteen different direct-to-consumer medical teleconsultation platforms were identified across the three provinces. The quality of these teleconsultation platforms was very heterogeneous. The landscape of virtual primary care is changing rapidly in the Canadian ecosystem, and the transparency of current teleconsultation platforms could be improved.

Home-based “Virtual” Primary Care - Opportunities and Challenges

Topics addressed include:
 
 How does the "primary care" model consumers want virtually play out in the home? 
 What is required for success? 
 What are the best scenarios for virtual primary care, and what are the limitations?
 Can we create a solution with all the benefits of virtual and overcome perceived limitations, too?

General practitioners' perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study.

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. We explored GPs' perspectives on the main benefits and challenges of using digital virtual care. GPs across 20 countries completed an online questionnaire between June-September 2020. GPs' perceptions of main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. 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 patients' preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital virtual 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. 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 and secure.

Public Experiences and Perspectives of Virtual Primary Care Visits: Outcomes and Future Options

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

"Beyond Just a Supplement": Administrators' Visions for the Future of Virtual Primary Care Services.

The COVID-19 pandemic resulted in unprecedented adoption and implementation of virtual primary care services, and little is known about whether and how virtual care services will be provided after the pandemic ends. We aim to identify how administrators at health care organizations perceive the future of virtual primary care services. In March-April of 2021, we conducted semistructured qualitative phone interviews with administrators at 17 health care organizations that ranged from multi-state nonfederal delivery systems to single-site primary care practices. Organizations differed in size, structure, ownership, and geography. We explore how health care administrators anticipate their organization will offer virtual primary care services after the COVID-19 pandemic subsides. All interviewed administrators expected virtual primary care services to persist after the pandemic. We categorize expected impact of future virtual services as limited (n = 4); targeted to a narrow set of clinical encounters (n = 5); and a major shift in primary care delivery (n = 8). The underlying motivation expressed by administrators for providing virtual care services was to remain financially stable and competitive. This motivation can be seen in the 3 main goals described for their anticipated use of virtual services: (1) optimizing medical services; (2) enhancing the patient experience; and (3) increasing loyalty among patients. Health care organizations are considering how virtual primary care services can be used to improve patient outcomes, access to care, and convenience of care. To implement and sustain virtual primary care services, health care organizations will need long-term support from regulators and payers.

Differences in access to virtual and in-person primary care by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system

BackgroundResearch exploring telehealth expansion during the COVID-19 pandemic has demonstrated that groups disproportionately impacted by COVID-19 also experience worse access to telehealth. However, this research has been cross-sectional or short in duration; geographically limited; has not accounted for pre-existing access disparities; and has not examined COVID-19 patients. We examined virtual primary care use by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system. We also assessed use of in-person primary care to understand whether disparities in virtual access may have been offset by improved in-person access.MethodsUsing a cohort design, electronic health records, and Centers for Disease Control and Prevention Social Vulnerability Index, we compared changes in virtual and in-person primary care use by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our study population included 11,326 adult patients diagnosed with COVID-19 between March and July 2020. We estimated logistic regression models to examine likelihood of primary care use. In all regression models we computed robust standard errors; in adjusted models we controlled for demographic and health characteristics of patients.ResultsIn a patient population of primarily Hispanic/Latino and non-Hispanic White individuals, and in which over half lived in socially vulnerable areas, likelihood of virtual primary care use increased from the year before to the year after COVID-19 diagnosis (3.6 to 10.3%); while in-person use remained stable (21.0 to 20.7%). In unadjusted and adjusted regression models, compared with White patients, Hispanic/Latino and other race/ethnicity patients were significantly less likely to use virtual care before and after COVID-19 diagnosis; Hispanic/Latino, Native Hawaiian/Pacific Islander, and other race/ethnicity patients, and patients living in socially vulnerable areas were also significantly less likely to use in-person care during these time periods.ConclusionsNewly expanded virtual primary care has not equitably benefited individuals from racialized groups diagnosed with COVID-19, and virtual access disparities have not been offset by improved in-person access. Health systems should employ evidence-based strategies to equitably provide care, including representative provider networks; targeted, empowering outreach; co-developed culturally and linguistically appropriate tools and technologies; and provision of enabling resources and services.

Health Tech Analyst Commentary & Market Watch

The panelists presents valuable market intelligence from leading experts including M&As, NewCos, SPACS, speculative bubbles, evaluating the consumer and provider experience, Big Tech failures and successes and future predictions. Why are public telehealth companies doing poorly and why are “niche” telehealth companies getting so much investor money? What are the major hurdles for the widespread adoption of virtual primary care tools, and what are views on new entrants in the marketplace such as Amazon Care?

Assessing Public's Perspective on the Use of Virtual Primary Care During the COVID-19 Pandemic: An Exploratory Approach Using Topic Modelling

Assessing Public's Perspective on the Use of Virtual Primary Care During the COVID-19 Pandemic: An Exploratory Approach Using Topic Modelling

Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic

Introduction With the onset of Coronavirus disease (COVID-19), primary care has swiftly transitioned from face-to-face to virtual care, yet it remains largely unknown how this has impacted the quality and safety of care. We aim to evaluate patient use of virtual primary care models during COVID-19, including change in uptake, perceived impact on the quality and safety of care and willingness of future use. Methodology An online cross-sectional survey was administered to the public across the United Kingdom, Sweden, Italy and Germany. McNemar tests were conducted to test pre- and post-pandemic differences in uptake for each technology. One-way analysis of variance was conducted to examine patient experience ratings and perceived impacts on healthcare quality and safety across demographic characteristics. Results Respondents (n = 6326) reported an increased use of telephone consultations ( + 6.3%, p < .001), patient-initiated services ( + 1.5%, n = 98, p < 0.001), video consultations ( + 1.4%, p < .001), remote triage ( + 1.3, p < 0.001) and secure messaging systems ( + 0.9%, p = .019). Experience rates using virtual care technologies were higher for men (2.4 ± 1.0 vs. 2.3 ± 0.9, p < .001), those with higher literacy (2.8 ± 1.0 vs. 2.3 ± 0.9, p < .001), and participants from Germany (2.5 ± 0.9, p < .001). Healthcare timeliness and efficiency were the dimensions most often reported as being positively impacted by virtual technologies (60.2%, n = 2793 and 55.7%, n = 2,401, respectively), followed by effectiveness (46.5%, n = 1802), safety (45.5%, n = 1822), patient-centredness (45.2%, n = 45.2) and equity (42.9%, n = 1726). Interest in future use was highest for telephone consultations (55.9%), patient-initiated digital services (56.1%), secure messaging systems (43.4%), online triage (35.1%), video consultations (37.0%) and chat consultations (30.1%), although significant variation was observed between countries and patient characteristics. Discussion Future work must examine the drivers and determinants of positive experiences using remote care to co-create a supportive environment that ensures equitable adoption and use. Comparative analysis between countries and health systems offers the opportunity for policymakers to learn from best practices internationally.

Enhancing Digital Empathy and Reimagining the Telehealth Experience

As telehealth is increasingly adopted across all care settings, it is important to understand how clinicians can adapt and respond to patient needs. Drawing from experiences of a virtual primary care physician and a patient advocate, this Perspectives editorial provides additional insights beyonds the telehealth basics for establishing digital empathy and a remote therapeutic connection.

Designing Virtual Primary Care: Desire or Dread? How Structural Forces Shape the Anticipation of Futures

The COVID‐19 pandemic changed many healthcare companies’ priorities and dramatically accelerated the drive towards increasingly virtual health care. Grand Rounds Health∗, a healthcare startup, decided the time is now to launch its virtual primary care offering. It was assumed that a rural, lower‐socioeconomic population would be more eager for, and best served by, virtual primary care, given their greater geographic distance from clinicians and other assumed access deficits. However, ethnographic research revealed that it was the urban, higher‐socioeconomic population who both reported far more favorable experiences with remote care and more eager anticipation of virtual primary care. This is partly due to different technological experiences and ecosystems, but more directly due to differing trust in and agency with institutionalized health care. Ultimately, this case study reminds researchers that our experiences are shaped and limited by our social positions, and that we cannot know if the framing of our inquiry is adequate.

Employer-Sponsored Health Centers Provide Access to Integrated Care via a Hybrid of Virtual and In-Person Visits.

Background: Since the explosion of telemedicine resulting from the SARS-CoV2 pandemic, employers have been particularly interested in virtual primary care as a novel means of expanding primary care services. The purpose of this study is to describe a model of integrated care delivered both in-person and virtually at employer-sponsored health centers nationwide. The key outcomes of this analysis were the proportion of all care delivered in-person and virtually by clinical discipline, the types of care and member satisfaction for care delivered in-person and virtually, and a description of the use of multiple clinical disciplines by the employee population.Methods: Retrospective observational study comparing health services utilization of primary care, behavioral health, and physical medicine services both in-person and virtually in employer-sponsored clinics between January 1, 2020 and June 30, 2021.Results: Of the 331,967 visits with employer-sponsored health center staff, 63% were in-person and 37% were delivered virtually. Most visits were for primary care services (59.5%), with physical medicine visits and behavioral health visits accounting for 25.1% and 15.4%, respectively. Whereas the preponderance of behavioral health visits were virtual visits (72.5%), less than a quarter (18.2%) of physical medicine visits were delivered virtually. 19.6% of patients were seen by more than two clinical disciplines and 2.6% were seen by three different disciplines. Overall, patients were highly likely to recommend the health center across both modalities (Net Promoter Score 89.1 for in-person care and 88.4 for virtual care).Discussion: The future of employer-sponsored integrated team-based care may require a hybrid approach that can lean heavily on virtual visits but requires the infrastructure necessary for in-person care.

Pediatric primary care in Ontario and Manitoba after the onset of the COVID-19 pandemic: a population-based study.

Background:There were large disruptions to health care services after the onset of the COVID-19 pandemic. We sought to describe the extent to which pandemic-related changes in service delivery and access affected use of primary care for children overall and by equity strata in the 9 months after pandemic onset in Manitoba and Ontario.Methods:We performed a population-based study of children aged 17 years or less with provincial health insurance in Ontario or Manitoba before and during the COVID-19 pandemic (Jan. 1, 2017–Nov. 28, 2020). We calculated the weekly rates of in-person and virtual primary care well-child and sick visits, overall and by age group, neighbourhood material deprivation level, rurality and immigrant status, and assessed changes in visit rates after COVID-19 restrictions were imposed compared to expected baseline rates calculated for the 3 years before pandemic onset.Results:Among almost 3 million children in Ontario and more than 300 000 children in Manitoba, primary care visit rates declined to 0.80 (95% confidence interval [CI] 0.77–0.82) of expected in Ontario and 0.82 (95% CI 0.79–0.84) of expected in Manitoba in the 9 months after the onset of the pandemic. Virtual visits accounted for 53% and 29% of visits in Ontario and Manitoba, respectively. The largest monthly decreases in visits occurred in April 2020. Although visit rates increased slowly after April 2020, they had not returned to prerestriction levels by November 2020 in either province. Children aged more than 1 year to 12 years experienced the greatest decrease in visits, especially for well-child care. Compared to prepandemic levels, visit rates were lowest among rural Manitobans, urban Ontarians and Ontarians in low-income neighbourhoods.Interpretation:During the study period, the pandemic contributed to rapid, immediate and inequitable decreases in primary care use, with some recovery and a substantial shift to virtual care. Postpandemic planning must consider the need for catch-up visits, and the long-term impacts warrant further study.