Day by Day

Telehealth use (care at a distance using information and communications technologies)(Wootton, 2012) became the most practical option for general practice consultations during COVID-19 Alert Levels 3 and 4 (Hollander & Carr, 2020) after 23 March 2020. The priority was to limit exposure to COVID-19 while accessing and or providing care. Telehealth includes the provision of pharmacy care at a distance, involves activities such as clinical services, patient counselling and monitoring, medication selection, order, review and dispensing, and IV admixture and administration (Alexander et al., 2017). Within days of the COVID-19 pandemic announcement, pharmacies set up telehealth processes (and associated software) and services continued throughout the lockdown the ongoing lockdown levels.

Person-focused care recognises the longitudinal relationship between clinician, e.g. pharmacist, and patient that incorporates multiple interactions about a mixture of long and short term health issues over time (Starfield, 2011). This approach, in turn, assumes the inclusion of different modes of interaction, such as in-person visits, video and phone discussions and consultations, and email/secure message correspondence.

Penchansky and Thomas (1981) describe access to care in terms of dimensions of accessibility, availability, affordability, service design, acceptability, implementation and design, and Saurman (2016) adds awareness (knowing that a service is available) as the final dimension. Telehealth is one way to enable access to care but could potentially become a barrier in terms of equity, where one assumes the availability of technologies and skills to be able to participate in, for example, a video consultation.

Traditional telehealth research highlights that there are lower costs for both consumer and provider, the convenience of phone/video consultations, and that there is no difference in service utilisation or disease progression for people with long term conditions (Greenhalgh, Wherton, Shaw, & Morrison, 2020). However, the introduction of video for telehealth (as opposed to the phone) has been accompanied by disruption in processes, and concerns in clinical quality and accountability, and patient privacy (Day & Kerr, 2012; Greenhalgh et al., 2020).

The International Covenant on Economic, Social and Cultural Rights treaty (WHO, 2020) outlines the right to equitable health care. New Zealand has an obligation under Te Tiriti o Waitangi to ensure improved health is equitably accessed for both Māori and non-Māori (Robson & Harris, 2007). Changes resulting from the introduction of telehealth must consider whether the new processes will result in improved health outcomes, and be accessible equitably. With these considerations in mind, how to upscale telehealth from emergency use to business as usual requires understanding of the consumer experience in the post emergency Covid19 period. 

To understand how users perceive future adoption of video, phone, email and messaging for pharmacy-patient interactions, a user’s intention to use telehealth technology after having experienced it, is important. The Unified Theory of Acceptance and Use of Technology (UTAUT) asserts that if there is perceived ease of use, perceived usefulness, and positive social norm (peer support for adoption), one can predict user acceptance. To make sense of the intent to use theory (UTAUT) we will contextualise the findings in the theory of access to care by Penchansky and Thomas (1981).

Therefore, in the context of New Zealand community pharmacy practice and the COVID-19 pandemic, our research question is, “What is the pharmacy provider’s experience of access to telehealth and how do they perceive this mode of care delivery going forward?” Once the provider experience is clear, the research will be extended to consumer experiences in the same way we did it for general practice.   

Research aim: To explore community pharmacy’s use of video, phone, email and messaging interactions since the 23^rd of March 2020 to describe (1) factors (negative and positive) about pharmacy providers’ use of telehealth; and (2) perceptions of consumers and providers regarding future use of telehealth.  

Research objectives: To achieve the research aim we will

• Conduct a scoping literature review
• Design two questionnaires (consumer and provider) to gather data. We will start with pharmacy providers as their use is unknown at this stage. The results will inform development of the consumer questionnaire.  
• Use the UTAUT to measure the acceptability of telehealth-related technology (video, phone, email, and messaging) and attitudes to future use of telehealth
• Contextualise the UTAUT findings using the access to care model (Penchansky & Thomas, 1981) and equity as lenses.
• Publish the findings as an exploratory descriptive study to establish a base for future research.

Methods

Pharmacists, intern pharmacists and pharmacy technicians who work in community pharmacies will be included in this study. They will be sent a questionnaire to complete electronically on either their mobile phone, laptop or desktop computer.

Data gathering (questionnaire)

The questionnaire contains questions related to

• Demographics (age, gender, ethnicity, confidence with computers, computer devices they use, internet access)
• Access to a telehealth consultation (e.g. how an appointment was made, how video and phone consultations occurred, and how email and messaging were used)
• Access to care (Penchansky and Thomas (1981) framework)
• Acceptability of heath care by telehealth and intention to use video and/or phone again for consultations (using the UTAUT theory of user acceptance of technology (Venkatesh, Thong, Chan, Hu, & Brown, 2011))

The questionnaire is online and will be distributed via professional pharmacy organisations to their members.

Data analysis

We will statistically analyse the data. The study design is reflected in the statistical analysis, which will use a combination of exploratory and descriptive statistical techniques to summarize and explore the collective experiences of community pharmacists.

As this study is not testing any particular hypothesis, no specific power calculations are required. Effect size tests like Cohen’s D will be used where appropriate.

Survey distribution plan (recruiting participants)

Since this survey is aimed only at pharmacy staff, we will distribute it via the three main professional pharmacy organisations, i.e. the Pharmaceutical Society of New Zealand, The Pharmacy Guild of New Zealand, the Independent Pharmacist Association, and Green Cross Health. There are 3,071 registered pharmacists working in approximately 1,100 community pharmacies in NZ. The survey link and QR code will be distributed via these three organisations via e.g. newsletters that are usually emailed to members. 

Outputs

We aim to describe provider experiences of telehealth since the COVID-19 pandemic physical distancing requirements began, focusing on access to telehealth and perceptions about future use intention.  This will contribute to policy development around how telehealth can be upscaled and sustained for ‘business as usual’ that is accessible to all and improves health. We will use the results of the provider survey to inform the development of a consumer survey. The results will inform guidelines and policy regarding the use of telehealth. We will publish the results of this research in peer reviewed journals, present them at conferences, and at pharmacy meetings.

Timeline

We plan to distribute the survey as soon as ethical approval is granted. The survey will be available online for three months (probably September-December 2021). The data analysis will be done in the three months following this period by a University of Auckland summer research scholarship student under supervision by the research team. We expect to publish our results in scholarly journals by the end of 2022.

Future research plans

This study will provide a foundation for future research that includes in-depth exploration and examination of telehealth use in community pharmacy. The next step will be to explore consumer experiences of telehealth. We are planning to conduct in-depth research on the telehealth consultation experience of both consumers and providers.

Research team

Co-principal Investigators: Karen Day (University of Auckland), Inga Hunter (Massey University)

Co-investigators: Billy Allan (Ministry of Health), Harry Zheng (Ministry of Health), Chloe Campbell (Pharmaceutical Society of New Zealand), Greig Russell (Massey University), Fiona Moir (University of Auckland), Emily Gill (University of Auckland), Rachel Roskvist (University of Auckland) and Vasudha Rao (Massey University), Bert van der Werf (Auckland University). 

Research Advisory Panel

Maryann Heather, Rob McNeill, Gayl Humphrey, Grant Searchfield, Amio Ikihele, Ruth Large, Lisa Livingstone, Michael Hosking, Nathan Kershaw, Rebecca George, Samuel Wong.

Telehealth Leadership Group

This research is endorsed by the Telehealth Leadership Group. Ruth Large, Andrew Pankhurst, Scott Arrol, Grant Ardern, Linzi Birmingham, Janine Bycroft, Roy Davidson, Kyle Ford, Denise Irvine, Yariv Doron, Craig Green, Kanny Ooi, Grant Templeman, Lucy Westbrooke, Amio Ikihele, Charis Frethey, Faustin Roman, John Manderson, Paul Welford, Richard Li, Rommel Anthony, Steven Earnshaw, Inga Hunter, Chris Walsh, Deon York, Samuel Wong, President of the RNZCGP, Eileen Duddy, Juliet Rumball-Smith, Billy Allan, Alex Forsyth, Daniel Bernal, Christine Walsh. Details of their roles as per their website.

References

Alexander, E., Butler, C. D., Darr, A., Jenkins, M. T., Long, R. D., Shipman, C. J., & Stratton, T. P. J. A. J. o. H.-S. P. (2017). ASHP statement on telehealth. 74(9), e236-e241.

Day, K., & Kerr, P. (2012). The potential of telehealth ‘business as usual’ in outpatient clinics. Journal of Telemedicine & Telecare, 18(2), 1357-1633.

Greenhalgh, T., Wherton, J., Shaw, S., & Morrison, C. (2020). Video consultations for covid-19: British Medical Journal Publishing Group.

Hollander, J. E., & Carr, B. G. (2020). Virtually perfect? Telemedicine for COVID-19. New England Journal of Medicine

Penchansky, R., & Thomas, J. W. (1981). The concept of access: definition and relationship to consumer satisfaction. Medical Care, 127-140.

Robson, B., & Harris, R. (2007). Hauora: Màori Standards of Health IV. A study of the years 2000–2005. Wellington: Te Ropu Rangahau Hauora a Eru Pomare

Saurman, E. (2016). Improving access: modifying Penchansky and Thomas’s theory of access. Journal of Health Services Research & Policy, 21(1), 36-39.

Starfield, B. (2011). Is patient-centered care the same as person-focused care? The Permanente Journal, 15(2), 63.

Venkatesh, V., Thong, J. Y., Chan, F. K., Hu, P. J. H., & Brown, S. A. (2011). Extending the two‐stage information systems continuance model: Incorporating UTAUT predictors and the role of context. Information Systems Journal, 21(6), 527-555.

WHO. (2020, 2020). Gender, equity and human rights.   Retrieved 16 July, 2020, from https://www.who.int/gender-equity-rights/understanding/human-rights-definition/en/

Wootton, R. (2012). Twenty years of telemedicine in chronic disease management–an evidence synthesis. Journal of Telemedicine and Telecare, 18(4), 211-220.

Approved by the Health and Disability Ethics Committee on 27/9/2021 for three years, Reference AH2539.