CAPÍTULO II: APLICACIÓN DEL PROCEDIMIENTO PARA EL ANÁLISIS Y MEJORA DE LA
2.2 Caracterización general de la empresa INPUD ¨1ro de Mayo¨
It is important when studying alternatives to the face-to-face consultation to consider the potential for unintended consequences. There are numerous examples of technologies that have been tinkered with and adapted in the field,121some to the extent that their initial purpose is barely recognisable. Changes in one element of care provision can have an impact on other elements of care and the role of other staff. An example is Winthereik and Langstrup’s study,135in Denmark, of patient and professional behaviours in response to a new portal for pregnant women. The portal was introduced to help women with uncomplicated pregnancies to self-manage, with aims to free up resources for patients with more complicated conditions. They found that, although only a minority of participants engaged in the portal, those who did enacted their active and responsible involvementat the clinicrather than at home. The use of the portal, therefore, provided both more and less than was anticipated: it reconfigured relations in a way that is likely to alter the meaning of care, but not in a manner that was likely to free up resources. In addition, the health-care practitioners, who were supposed to be using the portal to maintain a complete and shared electronic record, were instead printing a paper record and adding their own hand-written notes. The health-care professionals ended up doing more work than before.
Key questions
As the conceptual map was developed, a series of key questions was created (Box 2). These questions were used to form the basis of an essay:‘What do we need to consider when planning, implementing and researching the use of alternatives to face-to-face consultations in primary healthcare?’. The essay was submitted to and accepted by theJournal of Digital Healthand published in September 2016.83The content of the essay overlaps with the material presented in this chapter, although the essay was designed for broader application beyond the study.
Case study guide
The findings of the review fed directly into the case study guide. The case study guide was produced to guide the focused ethnographers in their understanding of the required scope of data collection across the three case study sites. Each ethnographer came from a different background, and two had not conducted
BOX 2 Key questions to consider when planning, implementing and researching alternatives to face-to-face consultations
Key questions
Organisational disruptions and dynamics Uptake
l How could patients find out what methods of consultation are offered by their doctor?
Organisation within the practice
l How will alternatives to the face-to-face consultation be scheduled into existing practice?
l What impact will alternatives to the face-to-face consultation have on reception and administrative staff work patterns?
l What are the agreed rules of engagement for the use of alternatives to the face-to-face consultation?
l What contingency is in place to ensure that communication by asynchronous methods is responded to,
and in a timely fashion?
l How will the expectations of all parties be managed?
l How can consultations be appropriately administered to avoid duplication of effort?
l How will alternatives to the face-to-face consultation be documented in the medical record, especially when consulting remotely from the practice?
l Is reimbursement for alternatives to the face-to-face consultation appropriate? What are the arrangements for reimbursement?
Ensuring safety in the organisation
l What are the potential patient safety issues?
l How are these (or might these be) mitigated?
l Are there risks to patient privacy and confidentiality?
Organisation of space
l What are the contingency arrangements for technology failure?
Professional disruptions and dynamics
Interface between technology and practice
l What did the designers intend it to do–and (more importantly) how is it used in practice?
Proximity in the consultation
l Does it allow eye-to-eye contact? Is it in real time or is it asynchronous?
l What is lost in comparison with the copresent consultation?
l What is the effect on valued aspects of primary care, such as the relationship and continuity of care?
l What is the alternative to the face-to-face consultation appropriate for? Is it offering a replacement for the face-to-face consultation or is it complementary?
l Is there a risk of misunderstanding as a result of the change in medium, and can this be accounted for?
l Will alternatives to the face-to-face consultation change how patients communicate?
Professional teams
l How are the roles of different team members affected by their use?
l Are there implications for staffing in the practice?
Medicolegal concerns
l How is medicolegal protection in relation to alternatives to the face-to-face consultation organised and understood in the practice setting?
Professional fears
l What are the views and concerns of different members of the team about alternatives to the face-to-face consultation?
Skills
l What skills are needed? Is training and support available?
l Will patients require training or guidance in using alternatives to the face-to-face consultation?
Policy
l Will the introduction of alternatives to the face-to-face consultation allow for flexible working?
l If so, might this have an impact on primary care staffing recruitment and retention?
l Are there cost implications? Spatial disruption and dynamics
The technology in practice
l Who was involved in setting up the system and whose work was considered?
l Is the rationale for introducing an alternative to the face-to-face consultation clear and understandable to all staff members?
l What impact does it have on all of the different members of the team?
l Whose core values and interests are served?
l How is resistance enacted, and by whom?
Patient interface with technology
l How will patient experiences be collected and recorded?
l Are there types of consultation that are preferred face to face?
l What about patients from groups who are often assumed to be disadvantaged in relation to alternatives to the face-to-face consultation (older, disabled, less educated, those with language difficulties)?
l How might patients use the opportunity to share digital files with their doctors? Unintended consequences
l Are there consequences (either positive or negative) for other elements of the practice, or other aspects of care provision?
l Are there consequences for other parts of the health system (use of emergency helplines, hospital emergency departments, etc.)?
l Do (and how do) staff and patients modify new forms of consultation to better meet their needs?
l How else might the planner, implementer or researcher identify unintended consequences?
BOX 2 Key questions to consider when planning, implementing and researching alternatives to face-to-face consultations (continued)
research in general practice settings before. The guide was used to ensure that they understood the scope of the focused ethnography and felt confident going into the field.
The guide outlined specific areas of interest, including the staff members they should consider observing (e.g. focusing on reception staff as well as clinical staff), things they might want to look out for (e.g. dynamics within the clinic between staff members) and where they might look (e.g. areas where team members interact beyond the consultation areas) in this particular setting.
The 13-page guide was written systematically, and began by reiterating the objective of the case studies and outlining the participants of interest. Then, for each group of interest, such as reception staff, the tasks required (observation, interview) and the per-protocol approach to conducting the tasks were outlined, and the factors to explore were detailed. These factors were derived from both the protocol and the review findings. The guide finished with a summary of each technology type and the specific factors to explore in relation to these. This was helpful for the ethnographers at the beginning of the study when they were unfamiliar with the research questions. They were told that it was a guide and not a checklist and that it was for their personal reference only. For the case study guide, seeAppendix 4.