Pre-pandemic evidence synthesis (published/submitted in late 2019) identifies a number of ‘barriers’ or ‘objections’ that justify the low uptake of alternative consultation mediums. For instance, a rapid evidence synthesis on ‘digital-first’ primary care, confirmed that uptake of digital channels for patient’s first point of contact was low, and identified concerns around technology, workload and confidentiality [1] as main barriers. A scoping review (focused on video consultations only) identified that this mode of delivery was not appropriate in many situations and as such face to face consultations were preferred [2].
Following the WHO’s announcement on the 11 March 2020 declaring Covid-2019 a pandemic [3], the radical change seen during the first year of the pandemic indicates how previously identified barriers and objections were rapidly overcome as shown in the below examples.
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In England, for example, data for older patients shows that the rate of remote consultations more than doubled between February and May 2020 [4], following a mandated move to total triage in the English National Health Service [5].
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In Netherlands, the shift from mainly face to face to virtual consultations happened within a week, as part of the pandemic response plans [6].
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In the United States, the implementation of the ‘Expansion of telehealth with 1135 waiver’ [7] signalled a critical regulatory move for Medicaid Services, with a 154% increase in the year to March 2020 [8].
A preliminary search for existing systematic reviews on this topic was conducted in PubMed and PROSPERO (an international database of prospectively registered systematic reviews in health and other areas where there is a health-related outcome [9] ) on the 23 February 2021 and 28 February 2021 respectively. Of 11 results in PubMed, only one related to primary care prescribing [10]. Of 27 protocols found in PROSPERO dealing with telemedicine since the declaration of the pandemic, only one makes direct reference to primary care [11]. Researchers with connected research were contacted given the potential overlap. The current version of the Cochrane library special collection on “Coronavirus (COVID-19): remote care through telehealth” (last updated on the 6 January 2021), only includes a review on healthworkers’ perceptions on telehealth in primary care [12]. Both PubMed and Prospero abstracts will be added to the screening pool.
Rationale. It is important to understand what lies at the core of the rapid shift to telemedicine following years of limited penetration. In the UK, both the Health Foundation [13] and the UK Comptroller and Auditor General [14] issued recommendations of the need of compiling lessons around service shifts accelerated by the pandemic and digital transformation respectively. This understanding is important to (i) address emerging concerns around potential disenfranchising of patients or particular population groups; (ii) support public discussions about future healthcare delivery; and (iii) evaluate and refine the change management approach based on system (and organisational) digital maturity.
To support greater understanding in these areas, this scoping review explores the move to telemedicine in the context of various health systems around the world during the first year of the pandemic, with a focus on primary care. This comparative approach around digitisation builds upon recent academic literature in the area, which so far has focused on either the digital aspect [15] or pandemic response [6], mostly in English-speaking countries. This research will seek to incorporate academic and non-academic literature through other documents in widely spoken languages to capture voices and experiences world-wide [16] .
Key definitions
Telemedicine. The review will focus on the clinical practice of telemedicine (the interaction between patient and clinician). As such it draws on the World Health Organisation’s definition of telemedicine [17].
“The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries […] all in the interests of advancing the health of individuals and their communities” (World Health Organization, 2010, p9).
Telemedicine will be defined, in the negative, as those modalities of clinician/patient interaction that do not require physical presence of the individuals in the same premises (either a primary care clinic or the patient’s home). In the positive, these are modalities where the clinician/patient interaction is held or mediated in a ‘virtual’ (as opposed to physical, premises-based) environment, through the use of a particular telecommunication technology. This definition is closely aligned with that provided by Sood et al, (2007) following a systematic review of over one hundred peer-reviewed perspectives [18]. In all cases the clinician is able to access and edit the patient’s record, and the appointment might be pre-scheduled, clinician-initiated or patient-initiated, synchronous or asynchronous.
These ‘virtual’ environments have been further described in Olayiwola et al., (2020) [19].
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Telephone visits: conversation happens over the telephone.
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Video visits: conducted through a (secure) video platform
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E-consultations: asynchronous discussions between clinician and patient, which are initiated by the patient through a patient portal which allows to specify their complaint. In some cases, the portals include a triaging protocol and allow to capture relevant details from the patient’s history.
In some settings, the terms ‘econsultations’ or ‘econsults’ can also apply to clinician/clinician discussions; but for the purposes of this review these will be excluded.
Primary care. Traditionally, primary care covers a multidisciplinary team of healthcare professionals dealing with areas related to communicable, non-communicable disease, prevention and management [20]. A standard definition is provided in the Alma Ata Declaration [21]:
“…essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”
The above definition also specifies this is a community-based (as opposed to a ‘hospital’/secondary care service). Hospital or secondary healthcare services, as well as educational activities will be excluded from the review. Notwithstanding the multidisciplinary nature of primary care, searches will focus on the consultations of doctors and nurses as medical professionals.
Population. The above definition of primary care also helps specify the population of interest, as healthcare services which are “universally accessible to individuals and families in the community” [21]. No population exclusion will be applied during the screening process.