Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study
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Abstract
BACKGROUND: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. OBJECTIVE: 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. METHODS: A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). RESULTS: 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 self-management. 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. CONCLUSIONS: 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.
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There was ambiguity in the use and variations of the term telehealth; three studies gave no definition and others defined variably; 11 articles (85%) used the terms "video telehealth," "telehealth," "telemedicine," or "telecare," while two used "video consultations".
“There was ambiguity in the use and variations of the term telehealth, with three studies giving no definition and others defining telehealth variably depending on study focus (Multimedia Appendix 3). The terms telehealth, telemedicine, and telemental health were common and often used interchangeably: 11 articles (85%) used the terms “video telehealth,” “telehealth,” “telemedicine,” or “telecare,””
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Opportunities for and challenges to spread and scale-up by type of clinical condition were reported in detail in only one study.
“Opportunities for and challenges to the spread and scale-up of video consulting by type of clinical condition were reported in detail in only one study [2,38].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Video consulting in an antenatal diabetes clinic was abandoned given involvement of multidisciplinary teams across departments, duration and severity of condition, and use of patient-held medical records unavailable to the clinician.
“For example, video consulting in an antenatal diabetes clinic was abandoned given the involvement of multidisciplinary teams across departments, the duration and severity of the condition (short-term, high-risk), and the use of patient-held medical records that were unavailable to the clinician conducting the video consultation [2,38].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Preoperative cancer surgery was deemed too complex for video consulting given necessity of a physical exam and likely no pre-existing relationship between patient and clinical team, but postoperative follow-up within the same clinic was deemed more appropriate.
“Preoperative cancer surgery was deemed too complex for video consulting given the necessity of a physical exam combined with there likely being no pre-existing relationship between the patient and clinical team, but postoperative follow-up within the same clinic was deemed more appropriate [2,38].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Challenges to and opportunities for widespread implementation for patients and caregivers were reported in 6 articles.
“Challenges to and opportunities for widespread implementation for patients and caregivers were reported in 6 articles [2,32-34,38,42].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Authors reported that support and high-quality training were necessary to achieve widespread growth.
“Authors reported that support and high-quality training were necessary to achieve widespread growth [2,32-43].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Upstream supply of technology was reported as a facilitator by Greenhalgh et al, who explained scale-up in a Skype-based service was facilitated partially by clear benefit for both technology supplier and patient.
“The upstream supply of technology (ie, the relationship between the organization and the supplier or developer) was reported as a facilitator by Greenhalgh et al [38], who explained that scale-up in a Skype-based service was facilitated partially by “clear benefit for both the technology supplier and the patient.””
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Of the reviewed articles that reported patient or caregiver challenges, these were primarily clinician perceptions rather than direct reports from patients or caregivers.
“Of the articles that did report patient or caregiver challenges [2,32-34,38,42], these were primarily clinician perceptions, rather than direct reports from patients or caregivers.”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Challenges such as the condition interact with the organization, determining the ability to scale up video consulting services.
“They reported how challenges such as the condition interact with the organization, determining the ability to scale up video consulting services.”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
In a UK study, although lack of clarity on remuneration was often raised as a key barrier by implementing teams, published policy documents rarely explained how reimbursement for virtual consultations would be implemented.
“In a UK study, the authors reported that, although lack of clarity on remuneration was often raised as a key barrier by implementing teams, published policy documents rarely explained how “reimbursement for virtual consultations would be implemented” [38].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Challenges reported in 5 reviewed articles included the labor-intensive process of scheduling video consultation appointments within and across organizations and the need to redesign organizational processes around the technology.
“Challenges reported in 5 articles included the labor-intensive process of scheduling video consultation appointments within and across organizations and the need to redesign organizational processes around the technology [2,36-38,40].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
At least one challenge or opportunity related to political, regulatory, cultural, contextual, or financial factors was reported in all 13 reviewed studies.
“At least one challenge or opportunity related to political, regulatory, cultural, contextual, or financial factors was reported in all studies (n=13) [2,32-43].”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
Embedding video consultations in a clinic involved significant reworking of processes to account for the virtual presence of the patient.
“how embedding video consultations in a clinic “involved significant reworking of … processes in ways that took account of the ‘virtual’ presence of the patient” [38]”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
In a scale-up of 4 video consulting services, the challenges and opportunities for each service were connected across the domains; simply assessing a patient as having a theoretically appropriate condition for video consulting and having a supportive national policy did not guarantee success.
“For example, in a scale-up of 4 video consulting services, the challenges and opportunities for each service were connected across the domains; simply assessing a patient as having a theoretically appropriate condition for video consulting (micro) and having a supportive national policy (macro) did not guarantee success.”
From Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (2021) · cites this paper as [38]
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- Authors
- Greenhalgh, T., Shaw, S., Wherton, J., Vijayaraghavan, S., Morris, J., Bhattacharya, S., Hanson, P., Campbell-Richards, D., Ramoutar, S., Collard, A., & Hodkinson, I.
- Affiliations
- University of Oxford (GB)
- Barts Health NHS Trust (GB)
- London Borough of Tower Hamlets (GB)
- Corresponding author
- Greenhalgh, Trisha
- ORCID
- Venue
- Journal of Medical Internet Research
- Publisher
- JMIR Publications Inc.
- Published
- 2018-04-17
- Volume
- 20
- Issue
- 4
- Pages
- e150
- ISSN
- 1438-8871 (ISSN-L)
- PMC
- PMC5930173
- OpenAlex
- W2801116222
- Cited by
- 371
- References
- 62
- Citations by year
- 2026: 20 · 2025: 41 · 2024: 33 · 2023: 46 · 2022: 75 · 2021: 77 · 2020: 45 · 2019: 22 · 2018: 12
- FWCI
- 37.12
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Journal of Medical Internet Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- Wellcome Trust (104830/Z/14/Z)
- National Institute for Health and Care Research (HS&DR-13/59/26, BRC-1215–20008, 13/59/26, NF-SI-0512-10031)
- University of Oxford
- Oxford University Hospitals NHS Foundation Trust
- Barts Health NHS Trust
- Health Services and Delivery Research Programme (13/59/26)
- NIHR Oxford Biomedical Research Centre (1215-20008, BRC-1215-20008)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Healthcare Systems and Technology
- Keywords
- telemedicine, Skype, scale-up, socio-technical change, patient self-management, diabetes mellitus, prenatal care, cancer surgery, teleconsultation, patient and staff experiences, organizational barriers, National Health Service, Roter Interaction Analysis System
- MeSH terms
- Delivery of Health Care, Female, Humans, Male, National Health Programs, Outpatients, Video Recording, Remote Consultation
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