Additional file 2: of Redesigning printed educational materials for primary care physicians: design improvements increase usability

Redesigned Version of the Therapeutics Letter.á…

Channel management in virtual care

Many virtual care initiatives focus heavily on video visits, essentially mimicking face-to-face visits. Meanwhile, clinicians in established settings continue to use the oldest modality, phone calls, and some use the most ubiquitous, asynchronous messaging. The latter, along with live chat and chatbots, could be transformative if workflows were redesigned to incorporate it. With multiple modalities now available for use in virtual care, the central problem is to direct patient-provider interactions to the channels generating the most value. Marketers call this channel management and use sophisticated approaches to implement it. We propose an adaptation of channel management to virtual care and discuss anticipated challenges to its implementation. </p

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.</p

Virtual care use prior to emergency department admissions during a stable COVID-19 period in Ontario, Canada

Background The increased use of telemedicine to provide virtual outpatient visits during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of virtual visits use prior to ED admissions and characterized the patients with prior virtual visit use and the physicians who provided these outpatient visits. Methods We conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization. Results There were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%). Interpretation The net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seemed to be able to appropriately triage patients to the ED and virtual visits replaced in-person visits ahead of ED admissions, as opposed to being additive.</p

Beyond “implementation”: digital health innovation and service design

Digital tools have shown great potential to enhance health services’ capacity to achieve the goals of the triple aim (enhance patient experience, improve health outcomes, and control or reduce costs), but their actual impact remains variable. In this commentary, we suggest that shifting from a perspective focused on “implementing” new digital tools in health care settings toward one focused on “service design” will help teams execute more successful digital technology adoption projects. We present value proposition design (VPD) as a service design strategy requiring that stakeholders are brutally honest in determining the value of a new digital tool for their everyday work. Incorporating a perspective focused on how the value proposition of a technology is understood by each team member, and implications for their work routines, will help project teams to better understand how services can be reinvented during technology adoption initiatives. We present the simple heuristic [Tool+Team+Routine] as a reminder of the central considerations that make up a service design initiative, and present an illustrative case scenario of designing the use of a digital care coordination platform in an actual digital technology adoption project. We conclude by outlining two important challenges that need to be addressed to advance service design approaches to technology adoption in health care.  </p

Primary and secondary outcomes of the toolkit intervention.

a<p>Adjusting for age, sex, diabetes duration, previous cardiovascular disease, and practice diabetes patient volume.</p>b<p>Among patients aged ≥65 years who were not already receiving the medication at baseline.</p><p>ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; CAD, coronary artery disease; ICC, intraclass correlation coefficient; OR, odds ratio.</p

Flow chart of practice and patient randomization in the trial.

<p>Flow chart of practice and patient randomization in the trial.</p

Patient and practice baseline characteristics, by study group.

<p><b>Number (%) except where indicated.</b></p>a<p>Only available in the clinical data study.</p>b<p>Only available in the administrative data study. Measured in the 10 months prior to the start of follow-up.</p>c<p>Among patients aged ≥65 years: 211,137 in the intervention group, 208,286 in the control group.</p><p>ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; CAD, coronary artery disease; SD, standard deviation.</p

Uptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in Canada

  Objectives To evaluate the uptake of a platform for virtual visits in primary care, examine patient and physician preferences for virtual communication methods and report on characteristics of visits and patients experience of care. Design A retrospective cohort study. Setting Primary care practices within five regions in Ontario, Canada after 18 months of access to virtual care services. Participants 326 primary care providers and 14 291 registered patients. Interventions Providers used a platform that allowed them to connect with their patients through synchronous (audio/video) and/or asynchronous (secure messaging) communication. Main outcome measures User-level data from the platforms including patient demographics, practice characteristics, communication modality used, visit characteristics and patients’ satisfaction. Results Among the participants, 44% of registered patients and 60% of registered providers used the platform at least once. Among patient users, 51% completed at least one virtual visit. The majority of virtual visits (94%) involved secure messaging. The most common patient requests were for medication prescriptions (24%) and follow-up from previous appointment (22%). The most common provider request was to follow-up on test results (59%). Providers indicated that 81% of virtual visits required no follow-up for that issue and 99% of patients reported that they would use virtual care services again. Conclusions While there are a growing number of primary care video visit services, our study found that both patients and providers in rostered practices prefer secure messaging over video. Despite fears that virtual visits would be overused by patients, when patients connected with their own primary care provider, many virtual visits appeared to replace in-person visits, and patients did not overwhelm physicians with requests. This approach may improve access and continuity in primary care.</p

Distribution of health focus of trans-national scale (TNS) and single-country programs (SCP).

<p>Distribution of health focus of trans-national scale (TNS) and single-country programs (SCP).</p