שנת סיום: 2023
כותרת עבודת הדוקטורט: Digital health transformation in Primary Care
מנחים: פרופ' אורנה בראון אפל ופרופ' טוני היימן
The use of telemedicine has grown rapidly in recent years and many in-clinic visits that were in the past face to face meetings are now performed remotely. Remote medical devices such as Tytocare™ are a new complementary addition to these consultations and may increase their utilization. Non face-to-face meetings (telemedicine) utilize a diverse range of innovative technological possibilities, including various applications and monitoring on the computer or cell phone, asynchronous and synchronous. Hybrid-medicine offers multi-channel options for the interaction between patients and their physician: 1. in-clinic visits, 2. Telemedicine - a synchronous Video Visit during office hours (VV) 3. Telemedicine - Video Visit with an option of a remote medical device (VVMD). While COVID-19 increased telemedicine use, healthcare providers are still seeking the best combination of virtual and in-clinic consultation. Understanding patients and physicians' usage and attitude is vital for achieving optimal implementation of this model.
The objective of this study was to investigate the facilitators and barriers of a hybrid health service implementation in a health maintenance organization in Israel. The specific aims of the study were (1) to examine both patient preferences and physician barriers and promoters for the use of the telemedicine services. (2) to examine whether telemedicine with or without a remote medical device is associated with increased or reduced utilization of medical resources (3) to identify the socio demographic characteristics and perceptions of patients who seek care via telemedicine visits compared to in-clinic visits (4) to examine the factors predicting the acceptance of video consultation with or without a technological medical device, their perceived ease of use and perceived usefulness as well as social behavioral factors.
Methods:
In 2019, Meuhedet, an Israel's healthcare services serving 1.3 million Israelis, launched a hybrid medicine program. This PhD. dissertation, includes four studies, each investigating one of the above mentioned aims, all studies are related to each other. Two methods of research were utilized: qualitative and quantitative. The utilization of various research techniques improved the internal validity and allowed for a more thorough examination in line with the research goals.
Phase 0 – Preliminary phase. We performed a mixed method study for the hybrid program pilot implementation period from May 2019 to November 2019, prior to Covid-19 pandemic. The study included patients' answers of a short self-reported survey of their VV experience and focus group discussion with physicians of the pilot, to assess their attitude toward the new technology and a retrospective report of the video visits using a thematic content analysis method. This provided the infrastructure for the doctoral dissertation. Based upon this, we designed the next phases.
Phase 1 – Qualitative research included focus groups of patients and physicians (separately).This was done in order to sharpen the research objectives and improve the study design. The discussion in the focus groups were on the topics of barriers and promoters of using and choosing telemedicine. In this study we used Descrete Choice Methodology and Think Aloud methods to identify the most important attributes for patients for choosing Hybrid Medicine (Manuscript 1) and iterative, thematic analysis in physicians group.
Phase 2 - Quantitative research included analysis of a retrospective cohort data extracted from HMO electronic medical records (EMR). Our study included all completed primary care visits of children aged < 18 from the 1st of April 2021 to the 28 of February 2022. Subsequent health care utilization was measured by outcomes of care including follow-up visits, referrals to subspecialists or additional medical services, laboratory test referrals and antibiotic prescriptions. (Manuscript 2).
Phase 3 – Cross-Sectional survey data collection and analysis based on patients who had visited a physician during the year 2021 and had the option to receive video consultations with or without remote medical devices. The questionnaire focused on perceptions towards usage of video visits and remote medical device. We used the framework of technology acceptance model, trust and shared decision. Structural equation modeling was applied to analyze the survey data. (Manuscript 3)
Findings:
I examined the adoption of telemedicine by patients, both at the individual and system level. At the individual level, the study identifies the behavior patterns of patients by examining the patients’ methods, factors, and motivations for choosing telemedicine (Manuscripts 1 and 3), while at the system level, it investigates the individual outcomes of these choices (Manuscript 2). The two levels are interrelated, with growing evidence indicating that patient experience (individual level) can impact clinical health outcomes and use of other medical services (system level). Studies highlight the importance of the patient-physician relationship in improving medical outcomes, safety, patient adherence, and satisfaction, and demonstrate the need for healthcare systems.
Individual Level (Manuscripts 1 and 3):
Our analysis revealed several key factors that patients consider when choosing medical visits, including availability, time until the appointment, severity of the medical problem, patient-physician relationship, and flexible reception hours. The study also found that social-technological factors, such as trust, shared decision making, ease of use, and usefulness, influence the patients' future intention to use telemedicine. Our findings support the Technology Acceptance Model (TAM), which emphasizes that perceived ease of use and perceived usefulness are crucial antecedents that directly affect the behavioral intention to use telemedicine. This study also assessed two additional variables in the context of the TAM model, trust and Shared Decision Management (SDM).
System Level (Manuscript 2):
The main findings indicate that care received through telemedicine consultations via video visits with a remote medical device (VVMD) in pediatric patients resulted in lower healthcare service utilization compared to video visits (VV) without a medical device. The rates of follow-up visits, referrals to subspecialists or additional medical services, and laboratory testing were lower in the VVMD group, but the rate of antibiotic prescriptions was higher. Patients or parents of patients with higher socio-economic status tended to use VV and VVMD more often compared to in-clinic visits. In general, telemedicine visits reduced healthcare services utilization compared to in-clinic visits, with the exception of follow-up visits. The results suggest that the utilization of telemedicine consultations can be improved through the use of a medical examination device. Our findings correspond with previous studies that found that referrals and laboratory test referrals were lower in telemedicine visit consultations, and increased follow-up visits. These findings are consistent with our findings (phase 0, phase 1) regarding physician barriers regarding Hybrid Medicine, including incorrect visit type selection by patients and the need for physical examination in-clinic or remotely by a device.
Practical Implications for Future Research
Despite the fact that this research was focused on a single telemedicine service in Israel the conclusions and practical implications may be relevant to many telemedicine service around the world. For those responsible for making decisions related to healthcare provision, it is important take into account patient socio-demographic profile if they hope to encourage a wider adoption of telemedicine. It is also imperative that healthcare systems are aware of the potential increased frequency of follow-up visits in telemedicine consultations and take appropriate measures to address this. The practical implications of this work for health services include the need to design telemedicine systems that are easy to use, to consider a broader implementation of medical devices, to provide improved guidance for physicians, to enhance physician and clinic availability for video consultations, and to improve guidance for patients and physicians to build trust and support shared decision-making.
Considering the limitations of this study, including the relatively small number of medical device visits finally analyzed, I recommend further studies in other telemedicine settings, analyzing a larger number of consultations. As telemedicine will be playing an even greater role in health care delivery in the future, it is important to continue to develop strong evidence-based information.
Conclusions
Our findings provide valuable insights into the use of video visits and remote medical devices as part of primary care. All in all, the study represents a contribution to the literature around health implementation, impact, facilitators and barriers, and addresses the question of what drives use and what impacts the health utilization with or without a remote medical device.
The findings offer new evidence on the impact of telemedicine on healthcare utilization and suggest that that use of a remote medical device during video visits appears to reduce utilization compared to video visits without such a device. These findings provide an additional data point in the discussion regarding use of video visits and remote medical device in children. The study's theoretical contribution lies in its examination of post-COVID-19 patients' preferences for hybrid medicine patient care, as well as its contribution to the limited existing literature on the development of attributes for discrete choice experiments of patient preferences. Additionally, the study extends the technology acceptance model by incorporating the constructs of trust and shared decision management in the context of video consultations in primary healthcare, which improves the explanation of the variability in telemedicine use. These results serve as a valuable resource for future policy and program development.