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Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a “burning platform” for scaling up such services. As health care organizations look to expand and maintain the use of video in the “new normal,” it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward.
This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19.
A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants (eg, clinicians, managers, administrators, and IT support), ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al’s 3 perspectives on crisis and digital change: as opportunity (for accelerated innovation and removal of barriers to experimentation), disruption (to organizational practices, generating new dependencies and risks), and exposure (of vulnerabilities in both people and infrastructure).
Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an “organizing vision” for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use.
For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed.
There has been growing interest in the use of video as a method of consultation between clinician and patient over the past 10 years, and numerous studies have shown such consultations to be acceptable, safe, and effective in selected patients [
COVID-19 created a “burning platform” for the mainstreamed use of such services, as health care organizations worldwide halted face-to-face appointments for nonurgent care. The global emergency prompted strategic (policy decisions and legal changes), operational (increasing capacity and delivery by building skills and resources at pace and scale), and regulatory (eg, pandemic-related unofficial workarounds with unregulated products) changes with regard to the delivery of telehealth across different national contexts [
During the first wave of the pandemic in 2020, most countries saw a rapid reduction in face-to-face consultations and an increase in remote ones in both primary and secondary care [
As health care organizations are looking to expand and maintain the use of video in the postpandemic “new normal,” it is important to acknowledge and harness wider system changes that have emerged. In this paper, we focus on the infrastructural aspects of the rapid scale-up of video and draw lessons for ongoing developments and sustainability. To this end, we explore the impact of the pandemic in 4 NHS organizations, where we had previously identified ways in which infrastructural features influenced the limited use of video in the years preceding the pandemic [
Star [
In the years before COVID-19, we conducted ethnographic research in 4 NHS organizations in England, all of which were seeking to introduce or scale up video consultations [
In our application and retheorization of Star’s [
A crisis is a low-probability, high-impact event that threatens social and life-sustaining systems, creates deep uncertainty, and requires international and government intervention [
In this paper, we provide longitudinal qualitative and quantitative data (spanning before and during the pandemic) on 4 NHS organizations to understand infrastructural changes during the rapid scale-up of video consultations and how this may influence sustainability going forward. All 4 sites saw a significant reduction in face-to-face appointments, and immediate and substantial increase in remote ones (overall a 245-fold increase in video consultations), as part of a systemwide response to the pandemic in 2020. Against this background, we sought to study how health information infrastructures shaped, and were shaped by, the rapid scale-up. In the remainder of this paper, we first describe the national context and aims of the study. In the Methods section, we describe the study setup and our analytical approach to understanding infrastructural features and challenges. We then describe our findings on crisis-engendered change as a time of opportunity, disruption, and exposure. Finally, we discuss the findings in the context of the wider literature, highlighting learning points for scaling up and sustaining the use of video beyond the pandemic.
Since 2010, there had been a growing policy emphasis on digital innovation and remote care in England [
In 2019, the year before COVID-19, NHS England and NHS Improvement (NHSEI, the national implementation arm of the NHS in England) set up several pilot video consulting services in secondary care using a video platform called Attend Anywhere (building on the learning of a similar program in Scotland) [
When the pandemic hit in March 2020, the use of remote consultations (phone and video) formed a key element of the national response [
NHSX (a cross-department unit within the NHS with responsibility for setting the national policy on digital and data management) advised on governance reviews of video platforms to facilitate organizational approvals, as well as the negotiation of zero-rated 4G with major mobile network providers (so patients could use Attend Anywhere without incurring mobile broadband charges).
The provision of Attend Anywhere across England was further supported by recent insights from prepandemic scale-up of Attend Anywhere in Scotland. In addition, the temporary use of the Scottish platform servers during the initial response allowed for immediate setup of the trust’s Attend Anywhere accounts before they were transferred to a dedicated server.
Across England, the proportion of remote consultations (phone and video) surged from just 3.9% of all outpatient activity in January-February 2020 to 36.6% by the end of April 2020. Over the course of 1 year (April 2020-March 2021), remote consulting accounted for, on average, 28% of outpatient activity (with a proportionate drop largely due to a gradual increase in the number of in person appointments) [
The aim of this study was to draw lessons from 4 NHS organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19. Our research question was, “How did information infrastructures shape, and become shaped by, the rapid implementation and scaling-up of video consultations during the pandemic, and what does this mean for scale-up and sustainability going forward?”
A naturalistic case study with an action research component was conducted in 4 NHS trusts in England, which we refer to by their pseudonyms: Petroc, Eastern, Southern, and Northern Trusts. All were seeking to introduce and scale up video consultations before and during the pandemic as part of a service improvement program, in which members of the Petroc team supported clinicians and managers in the 3 other trusts. Data sources included ethnographic field notes, interviews, consultation activity data, service evaluation reports, documents, and material artifacts.
Research ethics approval was obtained from London – Camberwell St. Giles Research Ethics Committee (ref. 19/LO/0550). An advisory group was established from the start to oversee both phases of the project, with wide stakeholder representation (eg, policy makers, organizational stakeholders, and patient groups) and a lay chair. The group provided input on study progress during 6-monthly meetings, as well as comments on project outputs by phone and email.
Data were collected in 2 phases, before and during the pandemic (the periods and data sources are presented in
In total, 90 interviews were conducted with 49 participants, including doctors, nurses, allied health professionals (AHPs), service managers, and admin and IT support. This included 43 (48%) interviews with 29 (59%) participants prepandemic and 47 (52%) interviews with 37 (41%) participants during the pandemic. In addition, 17 (35%) participants were interviewed in both phases, and 6 (12%) key informants were interviewed on multiple occasions within each phase.
Fieldwork was conducted in person before the pandemic but was, of necessity, conducted remotely during the pandemic. Interviews lasted between 30 and 60 minutes. Participants were asked to talk about their experience of supporting or using video consultations (or why they had chosen not to support/use this medium), including the progress of and the challenge in using (or supporting the use of) video and the impact of the pandemic. When interviewees talked in the abstract about problems and challenges, we asked them to describe specific examples of these.
Our data set of qualitative interviews was supplemented by evaluation data captured by local teams (eg, aggregated data on patient experience surveys and demographics), internal audits (staff engagement reports), policy documents (eg, digital strategy documents, information governance, service recovery plans), and standard operating procedures and training resources (eg, implementation procedures, guidance materials).
Video consultation activity was captured during March 2020-March 2021 as part of a national NHS England pilot using Attend Anywhere, which was the main video platform used within the sites.
Data sources for the 2 phases of the evaluation.
|
Phase 1 (prepandemic) | Phase 2 (during the pandemic) | Total | |
Period of data collection | January 2018-February 2020 | March 2020-July 2021 | 3 years, 7 months | |
Ethnographic observation (hours) | 180 hours | No ethnography possible due to the pandemic | 180 hours | |
|
||||
|
Petroc | n=22 (54%) | n=19 (46%) | 41 |
|
Eastern | n=5 (38%) | n=8 (62%) | 13 |
|
Southern | n=12 (52%) | n=11 (48%) | 23 |
|
Northern | n=4 (31%) | n=9 (69%) | 13 |
Interview participants |
7 doctors 5 nurses 3 AHPsa 8 managers 6 admin/IT staff |
10 doctors 3 nurses 7 AHPs 8 managers 9 admin/IT staff |
12 doctors 6 nurses 8 AHPs 10 managers 13 admin/IT staff |
|
Uptake statistics for video consultations, by NHSb trust | July 2019-February 2020 | March 2020-March 2021 | 21 months | |
Online patient survey reports | Postconsultations, user experience survey (Petroc Health) | Postconsultations, user experience survey (all 4 sites) | 5 patient surveys (N=4050) |
aAHP: allied health professional.
bNHS: National Health Service.
Interviews, field notes, and supporting materials collected during the pandemic phase were first used to gain familiarity with each case site and produce an organizational narrative on the impact of COVID-19. Following this familiarization phase, interview transcripts were then organized into a Microsoft Excel spreadsheet to identify emerging themes within Gkeredakis et al's [
Analysis of emerging subthemes was guided by Star’s [
Analysis was further guided by the literature on crisis management [
Pentland and Feldman [
Petroc Health is a multisite acute hospital trust located in a predominantly deprived and multiethnic part of London. It is 1 of the largest trusts in England, serving a population of 2.5 million. Since 2013, Skype had been used within a diabetes clinic to reduce did-not-attend rates. Building on the success of this pilot, the digital strategy team commenced a trustwide program in 2018 to spread use across outpatient services. However, progress was hampered by technical problems with Skype, including incompatibility with the new virtual desktop infrastructure (VDI, a virtualization technology that hosts a desktop operating system on a centralized server). Petroc joined the NHSEI Attend Anywhere pilot in October 2019, and 7 clinical services started using the platform by the time COVID-19 hit in March 2020. As part of the pandemic response, other members of the digital strategy team were drafted in to support scale-up (eg, training, deployment), with oversight from a cross-departmental covid executive group.
Southern Trust is a large multisite provider in a university city that had won awards as a digital innovator. It includes 4 hospitals serving a population of 655,000, with a relatively high proportion of young people aged 20-24 years (including university students). As part of the prepandemic scale-up program, 2 services (diabetes and orthopedics) started using Skype for Business. Although this software was supported by the trust network, licensing permissions and firewall restrictions created problems conducting video calls with people outside of the organization (eg, patients). A small group of clinicians sought to engage the information and communication technology (ICT) department into resolving these issues, but little progress was made due to other IT priorities. In July 2019, Southern Trust joined the NHSEI Attend Anywhere pilot, in which 4 services started using the platform. When the pandemic hit, the chief digital officer coordinated a trustwide deployment, with the support of 5 divisional digital leads to manage technical setup (eg, the provision of iPads to run video via secure Wi-Fi).
Eastern Trust runs 2 hospitals in a largely rural county. The catchment population of 1 million is predominantly White British, with a relatively high proportion of patients over 65 years. There was a prepandemic strategy to digitize patient records. However, the electronic patient record system had not yet been rolled out, and so the large majority of services still relied on paper-based records. A diabetes consultant’s initial attempts to pilot the use of Skype, as part of the prepandemic scale-up, were halted by the ICT department due to governance concerns. The trust joined the NHSEI Attend Anywhere pilot in November 2019, but none of the services started using the software until COVID-19. This meant extensive work was needed to prepare clinicians and administrative teams using the software, with training from the regional support team set up by the NHSEI.
Northern Trust provides hospital and community services across a built-up metropolitan borough, as well as small towns and rural areas. Although geographically the largest catchment area, it has the smallest patient population of approximately 500,000. The population is predominantly White British, with socioeconomically diverse regions, including areas of high deprivation, unemployment, chronic illness, substance misuse, and mental health problems. As an early participating site for the NHSEI Attend Anywhere pilot, prepandemic use of the video software began in July 2019, with a focus on reducing patient travel and strong senior management buy-in. By the time the pandemic hit, Attend Anywhere was being used in 6 clinical services. The implementation team continued to lead the deployment, with additional operational and training support brought in from the IT and business units.
Monthly video consultations across the 4 trusts during March 2020-March 2021.
In sum, the case studies present contextually different circumstances in relation to the geography and technical and organizational contingencies but show similar trends in the rapid scale-up of video consultations. The following sections highlight common themes in relation to how the information infrastructures shaped, and became shaped by, the rapid scale-up.
Viewing the pandemic as an opportunity for positive change highlights how the crisis helped accelerate processes that were stalling, questioned institutional norms and processes, and allowed for experimentation.
Before COVID-19, efforts to implement video were restricted by (to a varying degree across sites) pressures on human and financial resources, competing operational and strategic priorities, differing institutional logics (beliefs, assumptions, and practices that shape actions [
It’s difficult to make a financial case for video consultations, because we’re not reducing any activity in the system, but we are requesting new technology…And it is difficult timing for the trust to take on something that doesn’t even pay for itself…You need the senior leadership to see it as the next priority, but of course, there are hundreds of priorities. It is really challenging. It doesn’t happen overnight…
The prepandemic focus on the economic case echoed the dominant policy discourse that viewed digital solutions primarily in terms of enhancing efficiency [
However, in the wake of the pandemic, a national mandate to avoid direct clinician-patient contact on the grounds of safety (infection control) engendered collective action toward the rapid rollout, as the same project manager described:
All of a sudden, we have a level of support we never had before. Like from a very senior level. As soon as this [pandemic] happened, they put in temporary governance structures—the Pandemic Covid Outpatient Group—headed up by one of the most senior doctors in the trust. I’ve moved full-time on this and report to them. So, if I have any problems, I have someone to escalate to, who can do something about it…Also, the clinical system team [responsible for building electronic clinic schedules] usually take[s] weeks to implement changes. But I’ve been given permission to, basically, get in touch with them to say, “This is a priority.”
These new relations illustrate how a shared
An opportunity was also seen within the temporary suspension of regulative structures, allowing staff to bypass administrative burden and governance processes, which had previously thwarted attempts to introduce video:
Things kind of became, to an extent, easier to do. Previously, you would have a lot of bureaucratic hurdles and hoops to jump through. But we have come to a point where things just had to be done.
This brought a welcome cultural shift, providing greater autonomy and openness to change. In accordance with Scott’s [
Before [COVID-19], we had hearing aids where you could remotely program them, and I looked into setting up a remote programming clinic…I went to information governance, and they gave me this list, and I was like, “Oh it’s not worth it—not for a few patients.” So, I didn’t bother. And that’s terrible—I should have bothered. But it was too much work. But now, when we asked them, it went straight through to the medical director, and she just said, “Go ahead with it…” So, things progressed—which is what the NHS would struggle with sometimes.
As described before, regulatory constraints were also reduced through national measures by NHS England, including the central procurement of Attend Anywhere (enabling unrestricted use with no cost to trusts), endorsement of video platforms by national information governance bodies (enabling experimentation), and temporary tariffs for remote consultations (avoiding local commissioning requirements and associated system configurations).
However, although these were intended as
One challenge is, few of us want to change what we’ve got now [Attend Anywhere]. We will have to go through this procurement—because the region will be doing it on our behalf—and there is a slim chance another provider will be chosen, and that would be a real challenge for us.
Finally, the pandemic created an opportunity for clinician engagement. Before the pandemic, there was a striking difference between those who embraced the use of video with enthusiasm and other clinicians on the same teams who were reluctant or could not see the benefits of the change. Hurdles to adoption were less to do with needing to learn to use the technology and more related to professional concerns about patient safety, quality of care, and identity. However, during the pandemic, the perceived
There was quite a lot of resistance previously by medical colleagues. They felt it would affect the relationship. [COVID-19] has turned that on its head quite quickly.
Clinicians using video talked about the advantages over phone for basic visual assessments (“eyeballing” the patient) and nonverbal interaction. This was reflected in the video activity data across sites, in which a large proportion of consultations were conducted within psychiatry/psychology and mental health services (13,952/109,401, 12.75%, of overall video activity), pediatric services (12,964/109,401, 11.85%), musculoskeletal and orthopedic services (11,953/109,401, 10.93%), and physiotherapy (11,636/109,401, 10.64%).
Crucially, many clinicians described
You have to be very pragmatic [over video] about how you do your assessments. And all those special tests we used to do in the consultation room, we’re suddenly finding that we were not getting any value out of them. And we are now coming to realize, it is what the patients tell us, it is how they got out their chair to get their medication or how they turn around to tell their partner to turn the telly down—all these little functional cues that we are seeing. I’m finding video a lot more helpful than these clever tests we used to do.
Christianson et al [
However, although the pandemic provided a context to try out and reflect on the use of video, as predicted by Gkeredakis et al [
The big question for me is whether this change is permanent or just temporary…Are we going to see clinicians just not wanting to go back to the way they were working before, or are we going to see a slip in the use?
The absence of prepandemic groundwork within Eastern Trust also brought uncertainties about the extent to which the new service model can be socially and technically stabilized within the organization:
We built a bridge—and it was a pretty good bridge to jump over the river—but we didn’t build the foundations. We suddenly had the technology, instantly threw ourselves into it, and got over that river. But the bridge is a little insecure…As a major change project, you would never do that—implement a new technology, try to get hundreds on board, and then build the system to support it.
Viewing the pandemic as disruption highlights how staff had to adapt to widespread displacement of social and material environments, including the need to work from home. Technology shortages also demanded improvised use of computing equipment (an advantage of Attend Anywhere was that it could run on a personal device, as nothing needed to be downloaded). Staff needed to reorganize work routines to accommodate and support remote consultations in the face of prolonged uncertainty and disruption. Adaptive capabilities allowed some service provision to continue but also distorted work practices and created new demands and unintended consequences.
Clinic workflows are complex and structured around various interacting routines (eg, booking appointments, arranging prior tests, processing patients through the clinic) and associated spatial and material structuring devices [
Particularly during the early stages of the pandemic, clinicians relied on the telephone to consult with patients:
We turned all into blanket telephone—and in a sense that has been the legacy—and we haven’t moved forward with video clinics, because the telephone clinics have been kind of working…There is a logistical problem. If you see people at clinic, it is really easy because they turn up, there is a slip [of paper] with their name on the trolley, and you just come out, pick up the slip…And when you’ve seen them, they will leave—you can’t double-see them. With the phone, we don’t have that. You may get someone who does not answer, so you call the next person, and come back to them—but then of course, that next person wasn’t expecting a call at that time, so then doesn’t pick up…So at the moment, I’ll start the [in clinic] appointments, and the registrar starts on the phone list. And then, when there are some less complicated patients in clinic, the registrar sees them, and I start at the bottom of the phone list and work up.
This extract highlights how the “installed base” both enabled and constrained the rapid reorganization of clinic routines, which, in turn, became locally embedded. Feldman [
Similarly, the rapid expansion of video demanded a high degree of adaptation and emergence in accordance with local needs and contingencies. One of the main areas of focus was the management of patient “entry” into their video appointment. The main video platform (Attend Anywhere) uses a consistent URL for each clinic virtual waiting area. In the initial phase, most patients were sent the relevant waiting area URL on an appointment letter, which they would be required to write into their internet browser. Although quick to implement, this arrangement was prone to problems with typing errors and incomplete knowledge of the new process:
They send them a sheet. I guess it must say what they have to do, but it’s very limited. In fact, I don’t think they always even send that. Sometimes, they just send a letter saying log onto this [URL] address. And 9 times out of 10, the first time they use it, they’ll go onto Google Search…which just comes up with [Attend Anywhere] websites. And then, we say ‘No, you put it into the address bar at the top…”
In this extract, the clinician, patient, and administrative staff lack the mutual awareness [
However, over the course of the pandemic, various changes were made to help orientate patients, depending on local human and technical resources in place. Within Petroc, for example, existing (outsourced) text reminding services adapted the text message sent to patients so they could click directly onto the URL, although this relied on the patient having a smart phone.
Another route of entry, eventually established within Petroc, Northern, and Southern Trusts, was the trust website, in which patients could click a button for the relevant virtual waiting area, although this relied on the patient being able to navigate the website and locate the correct button. The following extract describes a common problem in which patients would turn up in the wrong virtual waiting area due to difficulties distinguishing between overlapping specialties. This created a high degree of “invisible routine articulation work” (work necessary for dealing with anticipated contingencies but that is not formalized or documented [
Patients select a waiting room to go into. But often, they would be waiting in orthopedics because they had seen that department previously…But we don’t have access to that waiting room. So, we would need to contact them and tell them to come out and go into the MSK [musculoskeletal] waiting area.
Organizational capability to endure, and even harness, locally driven adaptations depended on the people and connections in place to monitor and embed new practices. For example, the Northern Trust implementation team continued to engage with clinicians shortly after the rapid deployment of Attend Anywhere, during which they discovered some practitioners using an alternative platform (accuRx). This platform’s texting and video call functions aligned better with their particular workflows and systems, and so it became supported at the system level.
It was kind of by chance and through discussions that we found some people had started using [accuRx]...We realized it was building a bit of momentum amongst some clinicians. So, we officially approved it, did a bit of comms, and developed some training on how to use that platform.
Similarly, over the course of the pandemic, the developers of Attend Anywhere incorporated new design features based on user feedback, including the “consult now” function, allowing clinicians to send the URL link directly to patients via text or email.
The various sociotechnical arrangements to support patient entry reflect the generative tension between ostensive (generalized understanding) and performative (specific actions taken) aspects of routines [
Another example of process extension was clinicians’ use of the instant messaging feature to communicate with patients in the virtual waiting area (eg, to tell them whether the clinic is running late), in which patients may decide to wait or exit and re-enter at a later point. In some cases, the clinician and patient would jointly decide to abandon the video option and consult by phone instead (when clinically appropriate).
Although some service teams brought admin support into this process (eg, to monitor the virtual waiting area), it usually relied on the clinicians to manage. Participants talked about the need for a conceptual shift in the departmental management of these new digital spaces, if they are to be sustained:
If the patient has a face-to-face appointment, it isn’t just them instantly in with a clinician and instantly out with a clinician…Outpatient departments manage the physical outpatient space, but now we’ve got all of this virtual outpatient space…which actually…other than the patient and the clinician linking up together, nobody is managing that space to make sure that link-up happens correctly…We need to be taking responsibility, full responsibility—like we do for the physical space—of that virtual space.
Narrative network analysis of patient entry into video consultations.
Perspectives on exposure revealed infrastructural challenges and tensions to video consulting that have gone largely unnoticed. As Star [
Networks and servers came under significant strain during the first few months of the pandemic, resulting in periods of poor service reliability. Although these problems were dealt with promptly in collaboration with technology providers, local IT issues were poorly understood and more difficult to resolve:
It is difficult to test the consultation capacity, because it is very dependent on the volume of calls, how the platform is doing on that day…It is really difficult to test the actual performance because it can vary so much.
Additionally, access and dependability issues extended beyond the boundaries of the organization’s IT infrastructure, including “digital poverty” (eg, no smartphone, no webcam, limited data package). It was reported that video tended to be lower among groups with a greater health care need and already facing health inequalities, such as older people, low health literacy, weak social networks, limited mobility, limited transport, and psychological and mental health problems:
Some people don’t have [smartphones], they don’t have laptops, iPads. You have to be kind of fairly well off to be able to access video consultation. We’ve definitely seen a difference in what type of patients can and can’t access.
Clinicians talked about limited privacy in family households, as well as differences in network connectivity. Particularly for patients living in rural areas, audio-video quality was unreliable, impacting the quality of the consultation and sometimes resulting in the use of the telephone as a backup:
Because if you’re talking to someone and you’re trying to explain something or you ask them a question and then you have to wait 10 seconds for them to answer, then you think, “Are they not answering, or is it they’ve not heard me or, you know, is it the delay?”
It was often difficult to anticipate the needs and wishes of patients in advance, requiring flexible use, alongside nondigital alternatives. Digital exclusion was not merely down to whether a person could use technology, but cut across multiple technical and social elements, as described next:
I had to say to her, “I can see your background [on video].” And I don’t think she was comfortable with that…We have a large Asian population, where there is an element of larger families and smaller living spaces. If I access their space, I will not only be seeing them, I would be seeing their family. And they may not be comfortable with that…You have to be careful.
Mitigating digital exclusion was an effortful accomplishment between clinicians, patients, and their support networks. However, some early strategic work had begun within Northern Trust to establish local hubs for video appointments in partnership with community centers:
So now, if they need help accessing technology, they can get in touch with the community center—and we trained people in these community hubs to help people access the remote consultation. But also, in the community hub, they will get access to a full package of support, such as food packages…It has taken a while just engaging with these groups, making sure they are happy.
This extract reveals the role of collegial partnerships in order to coordinate and interface between the digital and material aspects of health care and community-based infrastructures. Perspectives on exposure, therefore, reveal not only weakness within the system but also strengths to be leveraged and built upon. In a similar vein, Sanner et al [
Gkeredakis et al's [
The focus on
Accounts related to
Research on information infrastructures highlights how technology-supported change needs to be cultivated in a way that acknowledges challenging organizational needs and the inertia of the installed base [
Despite the policy focus on digital [
First is the need to balance stability (and integration, security, and centralized control) on the one hand and openness to change (and emergence and local adaptability) on the other. Although regulatory changes during the pandemic may have brought a new-found agility to experiment and innovate, health care organizations must still ensure a high level of safety, security, and dependability [
Second, the extended use of remote consultations highlights a need to conceptualize information infrastructures beyond the boundaries of the health care organization. The ubiquitous use of extra-organizational ICT within professional work settings has prompted calls for more theoretical and empirical research into the intersection between institutional infrastructures and individual digital assemblages [
Third, close attention needs to be paid to routines and patterns of actions underpinning virtual appointments. Our findings on the disruptive forces of the pandemic resonate with other studies focusing on the redesign of care pathways using process-mapping methods [
Finally, it is important to bridge competing institutional logics with an overall narrative or organizing vision [
The strength of this study is that we undertook research at 4 sites before the pandemic, through which we had already identified the importance of information infrastructures on the implementation and use of video. This provided a unique opportunity to study crisis-engendered changes from the early stages. In addition, the case studies were conducted within a wider program of research on remote consultations across the United Kingdom, providing a wider national context to the organizational settings.
Pandemic restrictions meant that we could not undertake ethnographic work during this phase, and our data collection during this time was affected by the unprecedented pressures on NHS staff, raising potential sample biases toward those individuals with time available to speak with us. However, our positive and longstanding relationship with these sites helped mitigate such issues; the researcher had previously visited all sites on numerous occasions before the pandemic, adapted interview schedules, and was able to draw on multiple sources of data.
A further limitation of this study includes the question of how far we can generalize from our 4 case studies on the rapid scale-up of video consultations. Our theoretical analysis helped explain the empirical data on information infrastructures in our case sites but may not explain all aspects of such infrastructure in all contexts. We chose to focus on video consultations as a topic of academic interest because it exemplifies a promising innovation that has taken decades to scale up. We encourage others to apply the same theoretical lens to explore crisis engendered changes in other digital health contexts.
Gkeredakis et al’s [
allied health professional
information and communication technology
National Health Service
NHS England and NHS Improvement
We thank the research participants, including patients, health care staff, and wider stakeholders, who all gave generously of their time while working under considerable pressure.
Fieldwork for this study was funded by the Health Foundation, an independent charity committed to bringing about better health care for people in the United Kingdom under 2 research programs (496288 and 2133488). Additional funding for TG’s, SES’s, and JW’s salaries over the course of the study was provided by the UK National Institute for Health Research Oxford Biomedical Research Centre (BRC-1215-20008).
None declared.