Telemedicine Chapter 22: Telemedicine and Videoconferencing and Video Consultations / COVID-19

This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020

Systematic Reviews

Christensen, LF et al (2019) [Systematic Review] Patients’ and Providers’ Experiences With Video Consultations Used in the Treatment of Older Patients With Unipolar Depression: A Systematic Review[1]

This paper provides knowledge regarding the use of video consultations, especially for older people with depression. The results show that video consultations support mental health practice, especially as a useful alternative when face-to-face therapy is not possible. Any initial scepticism quickly disappeared when video consultations were experienced in action. The challenges seem to consist of technical problems and lack of support from staff. The experiences and satisfaction of older people with depression seem to be positive, although methodological limitations and deficiencies of the reviewed articles should be considered. More qualitative research is needed, and future studies should focus on specific diagnoses and providers’ experiences.

Orlando, JF et al (2019) [Systematic Review] Systematic review of patient and caregivers satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients’ health[2]

Telehealth is an alternative method of delivering health care to people required to travel long distances for routine health care. The aim of this systematic review was to examine whether patients and their caregivers living in rural and remote areas are satisfied with telehealth videoconferencing as a mode of service delivery in managing their health. The authors conclude that here were high levels of satisfaction across all these dimensions. Despite these positive findings, the current evidence base lacks clarity in terms of how satisfaction is defined and measured. People living in rural and remote areas are generally satisfied with telehealth as a mode of service delivery as it may improve access to health care and avoid the inconvenience of travel

Rush, KL et al (2018) [Systematic Review] Videoconference Compared to Telephone in Healthcare Delivery: A Systematic Review[3]

Telehealth is an important tool for ensuring accessible healthcare access particularly over geographical distances. Videoconference and telephone are two common telehealth modalities, yet little is known as to the relative advantage of these modalities. This review compares the effectiveness of videoconference versus telephone in the delivery of healthcare. The authors conclude that videoconference appears to offer advantages over telephone particularly improved provider diagnostic accuracy and reduced readmission rates. Evidence showed little differences between the two modalities in terms of patient outcomes. However, the small heterogeneous sample prevents generalizability of the findings. More research is needed in this area to determine the circumstances under which videoconference is superior to telephone as a telehealth modality

Chike-Harris, KE et al (2020) [Literature Review] Integration of Telehealth Education Into the Health Care Provider Curriculum: A Review[4]

A literature review of how telehealth care is integrated into various health care curricula. The authors conclude that a standardized telehealth curriculum needs to be developed, and national competencies need to be created, which will guide the development of standardized curriculum across health care training programs.

Gordon, HS (2020) [Observational Study] “I’m Not Feeling I’m Part of the Conversation” Patients’ Perspectives on Communicating in Clinical Video Telehealth Visits[5]

Clinical video telehealth (CVT) offers the opportunity to improve access to healthcare providers in medically underserved areas. However, because CVT encounters are mediated through technology, they may result in unintended consequences related to the patient-provider interaction. This study identified several themes related to patients’ perspectives on CVT. In general, patients expressed satisfaction with CVT visits including better access to appointments, shorter travel time, and less time in the waiting room. Yet, patients also identified several challenges and concerns about CVT visits compared with in-person visits, including concerns about errors in their care because of perceived difficulty completing the physical exam, perceptions that providers paid less attention to them, barriers to speaking up and asking questions, and difficulty establishing a provider-patient relationship. Patients reported feeling less involved during the visit, difficulty finding opportunities to speak, and feeling rushed by the provider.

Greenhalgh, T et al (2020) COVID-19: A Remote Assessment in Primary Care[6]

Most patients with COVID-19 can be managed remotely with advice on symptomatic management and self-isolation. Although such consultations can be done by telephone in many cases, video provides additional visual cues and therapeutic presence. Breathlessness is a concerning symptom, though there is currently no validated tool for assessing it remotely. Safetynetting advice is crucial because some patients deteriorate in week 2, most commonly with pneumonia.

Greenhalgh, T et al (2020)[Editorial] Video Consultations for COVID-19[7]

The rapid spread of COVID-19, and the fact that healthcare facilities could be sources of contagion, has focused attention on new models of care that avoid face-to-face contact between clinician and patient. There has been particular interest in video consultations, which are already being rolled out in many countries as part of national digital health strategies. This editorial discusses the appropriateness of video consultations for dealing with the coronavirus crisis, and the challenges involved in scaling up this model at speed.

Shaw et al (2020) [Ethnographic Study] Video consultations between patientsand clinicians in diabetes, cancer, and heart failure services: linguistic ethnographic study of video-mediated interaction[8]

Using conversation analysis, this study aimed to identify and analyse the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. We conducted an in-depth analysis of the clinician-patient interaction in a sample of videomediated consultations and a comparison sample of face-to-face consultations drawn from 4 clinical settings across 2 trusts (1 community and 1 acute care)in the UK National Health Service. The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer, and heart failure patients), 28 matched audio recordings of face-to-face consultations, and field notes from before and after each consultation. We also conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). Patients had been selected by their clinician as appropriate for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (e.g., technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases, a relative)to simultaneously follow instructions and manipulate technology (e.g., camera)to make it possible for the clinician to see and hear adequately. A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinicians and patients can work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via a video link.

Colucci, M (2019) A Matter of Communication: A New Classification to Compare and Evaluate Telehealth and Telemedicine Interventions and Understand Their Effectiveness as a Communication Process[9]

This article attempts to define functions and applications of telemedicine and telehealth in order to achieve a simplified and comprehensive taxonomy. This may be used as a tool to evaluate their efficacy and to address health policies from the perspective of the centrality of information in the healthcare. Starting from a lexical frame, telemedicine or telehealth is conceived as a communication means and their action as a communication process. As a performance, the communication is related to the health outcome. Three functions (telemetry, telephasis, and telepraxis) and nine applications are identified. Understanding the mechanisms of telemedicine and telehealth effectiveness is crucial for a value-driven healthcare system. This new classification-focusing on the end effect of telemedicine and telehealth and on the type of interactions between involved actors-moves toward a new and simplified methodology to compare different studies and practices, design future researches, classify new technologies and guide their development, and finally address health policies and the healthcare provision.

Donaghy, E et al (2019) [Qualitative Study]Acceptability, Benefits, and Challenges of Video Consulting: A Qualiative Study in Primary Care[10]

People increasingly communicate online, using visual communication mediums such as Skype and FaceTime. Growing demands on primary care services mean that new ways of providing patient care are being considered. Video consultation (VC) over the Internetis one such mode. The aim of this paper is to explore patients’ and clinicians’ experiences of VC. The findings were that the visual component of VCs offers distinct advantages over telephone consultations. When integrated with current systems VCs can provide a time-saving alternative to face-to-face consultations when formal physical examination is not required, especially for people who work. Demand for VC services in primary care is likely to rise, but improved technical infrastructure is required to allow VC to become routine. However, for complex or sensitive problems face-to-face consultations remain preferable.

Grondin, F et al (2019) [Conceptual Framework] Empathy in computer‐mediated interactions: A conceptual framework for research and clinical practice[11]

Empathy plays a crucial role in fostering positive social interactions and is elicited through verbal and nonverbal socioemotional cues. Computer‐ mediated communication (CMC) rapidly connects individuals at a distance but can partly filter out nonverbal cues. We draw from available telehealth and emotion communication literature to elaborate a cohesive conceptual framework of online empathy, a tool the field is currently lacking. The distinctive features of online communication and their impacts on the empathic interaction are described. We also detail strategies that users can employ to facilitate feeling, conveying, and being perceived as empathic in CMC.

Hammersley, V et al (2019)[Quasi-Experimental Study] Comparing the Content and Quality of Video, Telephone, and Face-To-Face
Consultations: A Non-Randomised, Quasi-Experimental, Exploratory Study in UK Primary Care[12]

Growing demands on primary care services have led to policymakers promoting video consultations (VCs)to replace routine face-to-face consultations (FTFCs)in general practice. This study concludes that VC may be suitable for simple problems not requiring physical examination. VC, in terms of consultation length, content, and quality, appeared similar to TC. Both approaches appeared less ‘information rich’ than FTFC. Technical problems were common and, though patients really appreciated VC, infrastructure issues would need to be addressed before the technology and approach can be mainstreamed in primary care.

Ignatowicz, A et al (2019)[Review]Internet Videoconferencing for Patient-Clinician Consultations in Long-Term Conditions: A Review of Reviews and Applications in Line With Guidelines and Recommendations[13]

The authors conducted a review of the existing reviews of literature relating to the use of Internet videoconferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The review was followed with an assessment of UK National Institute for Health and Clinical Excellence guidelines for patient care in the context of common long-term illnesses to examine where videoconferencing could be implemented in line with these recommendations. The review of reviews found no formal evidence in favour of or against the use of Internet videoconferencing. Patients were satisfied with the use of videoconferencing but there was limited evidence that it led to a change in health outcomes. Evidence of healthcare professional satisfaction when using this mode of communication with patients was limited. The review of guidelines suggested a number of opportunities for adoption and expansion of Internet videoconferencing. Implementing videoconferencing in line with current evidence for patient care could offer support and provide information on using a communication channel that suits individual patient needs and circumstances. The evidence base for videoconferencing is growing, but there is still a lack of data relating to cost, ethics and safety. While the current evidence base for Internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published. With more videoconferencing services added in more contexts, research needs to explore how Internet videoconferencing can be implemented in ways that it is valued by patients and clinicians, and how it can fit within organisational and technical infrastructure of the healthcare services.

Pappas, Y et al (2019) Diagnosis and Decision-Making in Telemedicine[14]

This article provides an analysis of the skills that health professionals and patients employ in reaching diagnosis and decision-making in telemedicine consultations. The authors hope the findings of this study can be used to inform training programs in telemedicine that focus on the development of effective skills for professionals and the provision of information to patients.

Sartori, D. et al (2019)Preparing Trainees for Telemedicine: A Virtual OSCE Pilot[15]

Provision of health care remotely, has become an essential means of delivering timely, cost-effective and efficacious care. The virtues of telemedicine are many; these include enhancing patient-centred home visits, providing just-in-time consultation, coordinating multidisciplinary care, and more. There has been recent recognition that formal telemedicine curricula and competency assessment will be necessary components of graduate medical education in the near future. Despite this, there exists a significant unmet need to prepare the next generation of trainees to develop the unique skills necessary for the practice of telemedicine.

Seuren, LM et al (2019) [Qualitative Study] Physical Examinations via Video for Patients With Heart Failure: Qualitative Study Using Conversation Analysis[16]

This study explores the opportunities and challenges of remote physical examination of patients with heart failure using video-mediated communication technology. It concludes that video examinations are possible in the context of heart failure services; however, they are limited, time consuming, and challenging for all involved; guidance and training are needed to support roll-out of this new service model, along with research to understand if the challenges identified are relevant to different patients and conditions and how they can be successfully negotiated.

Stommel, W et al (2019) [Conversation Analysis] Other-attentiveness in video consultation openings: a conversation analysis of video-mediated versus faces-to-face consultations[17]

For patients recovering from surgery, a video consultation is a suitable alternative to conventional consultations. Video consultations have been found to be beneficial, but little is known about their organization, compared to face-to-face consultations. In this article, we explore potential extra interactional work conducted by participants in video-mediated consultations. We focus on the beginning of the consultation. Our data consist of 39 recorded, postoperative, oncological consultations, both faceto-face and through video-mediated communication (VMC), which we analyzed using conversation analysis. Although surgeons commonly launched the beginning with an announcement of the pathology report as the reason for the consultation, we found that in VMC, “how are you?” was regularly inserted after the testing of the technology. The question is a suitable strategy, as it displays overt other-attentivemess, while also being medically relevant. However, subsequently, surgeons may unilaterally close the elicited self-report to then address the pathology report. Thus, the extra interactional work of other-attentiveness is again attenuated.

Atherton, H et al (2018) [Case Study] The Potential of Alternatives to Face-To-Face Consultation in General Practice, and the Impact on Different Patient Groups: A Mixed-Methods Case Study[18]

There is international interest in the potential role of different forms of communication technology to provide an alternative to face-to-face consultations in health care. There has been considerable rhetoric about the need for general practices to offer consultations by telephone, e-mail or Internet video. However, little is understood about how, under what conditions, for which patients and in what ways these approaches may offer benefits to patients and practitioners in general practice. The authors objectives in this mixed methods case study were to review existing evidence about alternatives to face-to-face consultation; conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives; recruit eight general practices as case studies for focused ethnographic research, exploring how practice context, patient characteristics, type of technology and the purpose of the consultation interact to determine the impact of these alternatives; and synthesise the findings in order to develop a website resource about the implementation of alternatives to face-to-face consultations and a framework for subsequent evaluation. The authors conclude that current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may be at odds with current policy, which encourages the use of alternatives. We have highlighted key issues for practices and policy-makers to consider and have made recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting.

Greenhalgh, T et al (2018)[Mixed-Methods Study]Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study[19]

The study sought to 1. define good practice and inform implementation of video outpatient consultations; and 2. generate transferable knowledge about challenges to scaling up and routinizing this service model. When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported selfmanagement. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

Morony, S et al (2018) Enhancing Communication Skills for Telehealth: Development and Implementation of a Teach-Back Intervention for a National Maternal and Child Health Helpline in Australia[20]

Telehealth professionals require advanced communication skills, in part to compensate for lack of visual cues. Teach-Back is a best practice communication technique that has been recommended but not previously evaluated for consumer telehealth. The authors implemented Teach-Back at a national maternal and child health telephone helpline. They describe the intervention and report telenurse experiences learning to use Teach-Back.

Shaw, S et al (2018)[Mixed-Methods Study] Advantages and limitations of virtual online consultations in an NHS acute trust: the VOCAL mixedmethods study[21]

The objectives of this study were to define good practice and inform digital technology implementation in relation to remote consultations. The Authors conclude that virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out across the organisation and scale-up to other organisations are likely to require considerable support.

Shaw, S et al (2018) [Qualitative Analysis] Qualitative analysis of remote consultations (QuARC): a study of technology-enhanced consultations in diabetes, cancer andheart failure[22]

This study identifies and analyses the communication strategies through which remote consultations are accomplished and produces guidance for patients and clinicians to improve the communicative quality of remote consultations. The authors hope the study findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the co-production of information and guidance about communication strategies to support successful remote consultations.

Edirippulige, S, Armfield, NR, (2017) [Literature Review] Education and Training to Support the Use of Clinical Telehealth: A Review of the Literature[23]

Despite a growing literature base, substantial investment, and policy changes within governments, the integration of telehealth into routine clinical care has been limited. The availability of appropriate systematic education and training for practitioners has been highlighted as necessary for strong adoption. However, the availability and nature of telehealthrelated education and training for practitioners is not understood. The authors carried out a review of the literature and conclude that published evidence in peer-reviewed literature on telehealth education and training is limited.

Tates, K et al (2017) [Experimental Study] The Effect of Screen-to-Screen Versus Face-to-Face Consultation on Doctor-Patient Communication: An Experimental Study With Simulated Patients[24]

This study aimed to examine 1. the impact of a consultation medium on doctors’ and patients’ communicative behavior in terms of information exchange, interpersonal relationship building, and shared decision making; and 2. the mediating role of doctors’ and patients’ communicative behavior on satisfaction with both types of consultation medium. In this study, the quality of doctor-patient communication, as indicated by information exchange, interpersonal relationship building, and shared decision making, did not differ significantly between web-based and face-to-face consultations. Doctors and simulated patients were equally satisfied with both types of consultation medium, and no differences were found in the manner in which participants perceived communicative behavior during these consultations. The findings suggest that worries about a negative impact of web-based video consultation on the quality of patient-provider consultations seem unwarranted as they offer the same interaction quality and satisfaction level as regular face-to-face consultations.

Armfield, N et al (2015) [Literature Review] The Clinical Use of Skype–For Which Patients, With Which Problems and in Which Settings? A Snapshot Review of the Literature[25]

Low-cost and no-cost software-based video tools may be a feasible and effective way to provide some telemedicine services, particularly in lowresource settings. One of the most popular tools is Skype; it is freely available, may be installed on many types of devices, and is easy to use by clinicians and patients. While a previous review found no evidence in favour of, or against the clinical use of Skype, anecdotally it is believed to be widely used in healthcare for providing clinical services. However, the range of clinical applications in which Skype has been used has not been described. The authors carried out a literature review in order to identify and summarize the clinical applications of Skype. They found 239 unique articles. Twenty seven of the articles met the criteria for further review. The use of Skype was most prevalent in the management of chronic diseases such as cardiovascular diseases and diabetes, followed by educational and speech and language pathology applications. Most reported uses were in developed countries. In all but one case, Skype was reported by the authors to be feasible and to have benefit. However, while Skype may be a pragmatic approach to providing telemedicine services, in the absence of formal studies, the clinical and economic benefits remain unclear.

Edison, K et al (2013) Content and Style Comparison of Physician Communication in Teledermatology and In-Person Visits[26]

The body of research is rapidly growing regarding the use of telemedicine in patient care, including cost-effectiveness, patient access, patient outcomes, etc. Less has been done describing physician communication during different aspects of the clinical visit during actual versus virtual patient visits. The purpose of this study was to evaluate dermatology healthcare providers’ communication via both modalities with regard to content and style. This research indicates that physician providers communicate with similar style and content whether using teledermatology or in-person.

Miller, EA(2011)The Continuing Need to Investigate the Nature and Content of Teleconsultation Communication Using Interaction Analysis Techniques[27]

The lack of systematically collected and analysed data about the effect of telemedicine on patient-provider communication is a frequently cited barrier for why video communication has yet to reach its full potential. Existing research provides little information about the subtle and detailed changes in communication that take place over video. Comprehensive investigations of actual medical encounter behaviour are therefore required, including verbal content analysis, which uses interaction analysis systems (IAS)to describe and categorize the communication that has taken place. Ten IAS studies were identified in the literature. Although it is difficult to generalize due to differences in methodology and context, some tentative conclusions can be drawn. First, on-site providers tend to be substantially less active than offsite providers, suggesting that the former typically serve as facilitators and observers, rather than active participants. Second, just as in the conventional face-to-face setting, providers’ utterances tend to predominate in telemedicine. Third, conventional patterns of more task-focused than socioemotional utterances tend to persist in telemedicine. However, some studies found telemedicine to be more patient-centred than conventional medicine, and others found it less so. The subtractive and enhancing effects of telemedicine on provider-patient relations and outcomes is not fully understood.

Agha, Z et al(2009)[Evaluation]An Evaluation of Patient-Physician Communication Style During Telemedicine Consultations[28]

The objectives of this study were to measure and describe verbal and nonverbal communication during clinical TM consultations and to compare TM with in-person (IP) consultations in terms of the quality of physicianpatient communication. The study findings indicate differences between TM and IP consultations in terms of physician-patient communication style. Results suggest that, when comparing TM and IP consultations in terms of physician-patient communication, TM visits are more physician centered, with the physician controlling the dialogue and the patient taking a relatively passive role. The authors note further research is needed.

Liu, X et al (2007) Doctor-patient Communication: A Comparison Between Telemedicine Consultation and Face-To-Face Consultation[29]

The objective of this study was to compare doctor-patient communications in clinical consultations via telemedicine technology to doctor-patient communications in face-to-face clinical consultations. It found that the time spent on the telemedicine consultation was substantially longer than the time spent on the face-to-face consultation. No statistically significant differences were found in the number of either closed or open-ended questions asked by doctors between both types of consultation. Empathyutterances, praise-utterances, and facilitation-utterances were, however, seen less in the telemedicine consultations than in the face-to-face consultations. The volume of the medical records was statistically smaller in the telemedicine consultations than in the face-to-face consultations. Patients were satisfied with the telemedicine consultation, but doctors were dissatisfied with it and felt hampered by the communication barriers. This study concludes that new training programs are needed for doctors to develop improved communication skills and the ability to express empathy in telemedicine consultations.

[1] Christensen LF, Moller AM, Hansen JP, Nielsen CT, Gildberg FA. Patients’ and providers’ experiences with video consultations
used in the treatment of older patients with unipolar depression: A systematic review [published online ahead of print, 2019
Nov 2].J Psychiatr Ment Health Nurs. 2019;10.1111/jpm.12574. doi:10.1111/jpm.12574 [Accessed 28 April 2020][