JMIR Publications

ABSTRACT

Background:

Until COVID-19, implementation and uptake of video consultations in healthcare was slow. But the pandemic created a ‘burning platform’ for scaling up such services. As healthcare organizations look to expand and maintain the use of video in the ‘new normal’, it is important to understand infrastructural influences and changes that emerged during the pandemic and which may influence sustainability going forward.

Objective:

To draw lessons from four NHS organizations on how information infrastructures shaped, and were shaped by, the rapid scale up of video consultations during COVID-19.

Methods:

Mixed-methods case study of four NHS Trusts in England before and during the pandemic. Data comprised 90 interviews with 49 participants (including, doctors, nurses, AHPs, service managers, admin and IT support), ethnographic field notes and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale up of video consultations. Analysis was guided by Gkeredakis’ [1] three perspectives on crisis and digital change: as ‘opportunity’ (for accelerated innovation and removal of barriers to experimentation), ‘disruption’ (to organizational practices, generating new dependencies and risks), and ‘exposure’ (of vulnerabilities in both people and infrastructure).

Results:

Before the pandemic, there was a strong policy push for video consultations as a way of delivering health care efficiently. But the spread of video consultations was slow, and adopting clinicians described their use as being ‘ad hoc’, rather than ‘business as usual’. When the pandemic hit, video consultations were rapidly scaled up across case sites. From an opportunity perspective, participants talked about changes to institutional elements of the infrastructure, which had historically restricted the introduction and use of video. This was supported by an ‘organizing vision’ about the role of video, bringing greater legitimacy and support, subsequently challenging conventional assumptions, norms, and governance structures. Perspectives on disruption centred on the reorganization of social, technical and material work environments. With the displacement of deeply embedded routines, new performative patterns of action emerged. Capacity to retain positive elements of such change required a judicious balance between the managerial top-down and the emergent bottom-up approaches. Perspectives on exposure foregrounded interrelated social, practical and technical impediments to video consulting, and the potential to accentuate health inequalities. This highlighted the need to attend to the materiality and dependability of the installed base, as well as social and cultural context of use.

Conclusions:

For sustained adoption at scale, healthcare organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support flexibility and process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative or ‘organizing vision’ within which the continued use of video can be framed.