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General practitioners’ perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study
['Edmond Li', 'Institute Of Global Health Innovation', 'Faculty Of Medicine', 'Imperial College London', 'London', 'United Kingdom', 'Rosy Tsopra', 'Inserm', 'Université De Paris', 'Sorbonne Université']
Date: 2022-05
Likewise, significant challenges have also been highlighted across the six domains of quality of care. These included patients’ preference for face-to-face care, the potential negative impact on communication, and the lack of equipment, internet access and digital skills of some patient groups. In addition, clinical uncertainty and potentially inappropriate decision making resulting in delays in diagnosis and treatment, unsuitability for certain consultations, as well as overuse and misuse of healthcare resources, were also mentioned. Challenges specific to healthcare providers included the lack of guidance and support, higher workload, and remuneration issues. From the health systems’ perspective, the long-established organisational culture, technological difficulties, implementation and financial issues, and inadequate accompanying supportive policies and regulatory legislation, were also challenges described by participants.
Benefits were identified in accordance with the six domains of quality of care. These included a reduction in exposure risks for COVID-19 transmission, ensuring access and continuity of care to those who need it, including those who had previously limited access to face-to-face consultations, enabling remote triage, in addition to improved patient convenience, communication, and empowerment. Benefits for healthcare providers included a greater work flexibility and more control over their schedules. Benefits for health systems included hastening the digital transformation through increasing awareness, trust, adoption, skills, and technical capacity, as well as driving changes in legal and regulatory frameworks.
Only GPs were included in this study; future research should focus on the inclusion of other healthcare professionals and patients. The themes identified as part of this analysis and the subsequent recommendations derived from them, may not be equally relevant for each individual country given the diverse forms of virtual care used and the differing COVID-19 induced healthcare demands of the respective national health systems. Further qualitative content analysis could provide novel insights on their relative importance for individual countries, and specific groups of GPs. It is also important to note that this study evaluates qualitatively GPs perceptions on the impact of remote care; future research using quantitative approaches to objectively evaluate potential changes observed is critical to validate these findings.
The results must be interpreted considering some limitations. Our findings are impacted by common limitations of survey research, including self-reported answers and self-selection sampling methods. The predominance of GPs working in predominantly urban settings (62%) might be a consequence of the sampling method or represent actual geographic variations on delivery of virtual care. While our results do not allow to draw specific conclusion on this matter, future research should aim to clarify geographic variations, within and between countries, in what concerns the availability and use of virtual primary care. The predominance of the urban setting and the fact that urban GPs’ likely work as part of multidisciplinary teams may have influenced their responses. It is worth noting that approximately 40% of our responses were still derived from GPs in rural or mixed settings, and thus should still allow for differing views to be captured.
This is the first international study to explore GPs’ perceptions on the main benefits and challenges of using virtual consultations in primary care. Participants took part from 20 countries worldwide, with diverse health care systems and levels of healthcare spending. The sample size was large, with participants varying in age, clinical experience, and type of primary care setting (urban, rural, or mixed). This study employed a methodologically rigorous approach, leveraging qualitative methods to capture rich, descriptive data on individual perceptions, attitudes, and behaviours [ 35 , 36 ], performed according to the Consolidated Criteria for Reporting Qualitative Studies criteria [ 37 ]. Finally, the main benefits and challenges were mapped against a widely recognised framework for Quality of Care [ 10 ], whenever possible. Finally, a set of recommendations was developed based on the main findings, to support providers and healthcare organisations translate the lessons learned into practice improvements.
Comparison with prior work
Remote primary care is widely recognised as an promising solution to ensuring both patient and provider safety by preventing direct physical contact, hence reducing morbidity and mortality during the COVID-19 pandemic [16,38,39]. However, important safety concerns also manifested, predominantly concerning diagnostic uncertainty. In this context, previous literature also report GPs’ concerns about clinical risk [40] and the need to establish escalation protocols to support clinicians decide when a transition to urgent in-person follow-up care, or even to emergency services, is required [39].
Our results underline that remote digital tools may be an effective way of delivering primary care. In line with these findings, a Cochrane systematic review (2015) demonstrated the use of telemedicine strategies to be associated with increased access to care and improved clinical outcomes in single chronic diseases, particularly in type 2 diabetes [41]. However, the interventions were heterogenous and the external generalisability of these findings remain unclear. Future research will be needed to address questions such as for which patients, and for which conditions, do virtual care tools actually improve effectiveness.
Participants highlighted that virtual care, particularly through remote triage, can reduce the number of unnecessary visits and thus have a positive impact on efficiency (i.e., minimising waste, including from an economic perspective). Few telehealth evaluations have examined the association between outcomes and costs of virtual care. While some reviews have found that virtual care can decrease the use of acute hospital services [42–44], there is less evidence in the primary care context [45]. On the other hand, our participants raised concerns about potential overuse and misuse by patients. In a recent study in Canada (2020) evaluating the uptake of a platform for virtual visits in primary care, Stamenova et al. observed that many virtual visits appeared to replace face-to-face visits, yet patients did not overwhelm physicians with requests [46].
Regarding timeliness of care, participants identified both potential advantages and disadvantages. Remote primary care has the potential to offer convenient access to a primary care provider without needing to take time-off work, arrange transportation, and spend time waiting for face-to-face visits. Participants were also concerned that barriers to the use of technology and difficulties inherent to a new mode of care delivery, could result in delays in diagnosis and treatment. There is sparse evidence on the subject. However, a recent study examined patient-initiated primary care visits in Kaiser Permanente Northern California (a system with over four million members) and concluded that, on average, telephone visits were scheduled 50% sooner than office visits [47]. These findings have profound implications, given that timeliness of care is associated with improved health outcomes [48].
Virtual care has been promised to reduce inequities in access to care for decades, particularly in rural and geographically remote areas [49–51]. In line with previous literature, our results demonstrate the ability of virtual care to overcome barriers for those who have physical limitations to attend a face-to-face meeting, but also highlight their potential to entrench existing inequities in access to care [52,53]. Published evidence shows that the transition to virtual primary care did not unfold in the same manner across communities [54]. Proactive efforts are therefore needed to identify and address both patient and provider-related digital barriers to avoid that the widespread implementation of virtual care in a manner which reinforces disparities in health access amongst already underserved and excluded groups [54]. Future research should also evaluate differences on the different types of solutions available in each country, whether these are free of charge or nor, and whether they are developed by private companies.
Equally, with regards to patient-centredness, a range of benefits and challenges have been identified. While participants consider that virtual care can improve convenience and patient empowerment, participants also acknowledge that it can have both negative and positive effects on communication. Another important challenge is patient preference for face-to-face visits. Preference theory suggests that patients will prefer a virtual consultation if they perceive its benefits as outweighing its burdens [55]. Multiple factors may influence patients’ preference, including the situation of care (i.e., patient’s perception of their clinical status, treatment requirements, and care pathway), the expectations of care, the demand of care (e.g., social situation, consequences of choice), the capacity to allocate resources (e.g., patient’s ability to allocate financial, infrastructural, social and healthcare resources) [56] and patients’ digital health literacy [57,58]. These factors may combine or compete and may be dynamic throughout the patient’s journey.
The pandemic has a transformational impact in hastening the digital transformation, and in particular increasing awareness, trust, and adoption of virtual care [16,59,60]. Challenges such as the lack of support, burnout, and remuneration issues, are balanced by a few benefits (i.e., flexibility in work location and a better control over schedule). However, to fully embrace the benefits postulated (e.g., greater flexibility to work remotely from home), healthcare systems must explore and implement the enablers required. Potential enablers include single sign-on, sharing of records across systems, electronic generation of form, and the creation of workspaces and secure interfaces without the need for laptops and VPNs [61]. While the rapid implementation of virtual consulting tools provides the ability to work more flexibly and from various locations, primary care leaders need to be supported and learn how to build effective teams via novel approaches [62].
At the health systems level, previous studies have indicated that implementation barriers depended on accreditation, payment systems, and insurance [63]. Prioritisation of financial investments into relevant infrastructure, greater emphasis on healthcare providers training, and updates to the corresponding legal and regulatory frameworks supporting their use, are equally required. Overcoming institutional inertia is likely to be more feasible post-COVID-19, given that clinical culture is expected to have evolved substantially after a year of daily use of virtual care delivery. As many of the existing guidance and policies on primary virtual care was drafted and implemented during the emergency phase, the experience attained, and evidence collected offers an opportunity to refine, optimise, and update the relevant accompanying legal and regulatory frameworks.
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