Telehealth use (care at a distance using information and communications technologies)(Wootton, 2012) became the most practical option for general practice consultations during Covid19 Alert Levels 3 and 4 (Hollander & Carr, 2020) after 23 March 2020. The priority was to limit exposure to Covid19 while accessing and or providing care. Within days general practices set up telehealth processes (and associated software) and patients were triaged into video and/or phone appointments or in-person where physical examinations of patients were required (Greenhalgh, Wherton, Shaw, & Morrison, 2020). The Ministry of Health set a directive that at least 70% of primary care consultations during lockdown levels 3 and 4 should be done by telehealth (video or phone) (Cole, 2020).

Continuity of care, as a process measure of access to care, remained a priority during this time. Continuity of care is the longitudinal therapeutic relationship between a doctor and patient (Wright & Mainous III, 2018), which is essential for patient-centred (Bodenheimer, Ghorob, Willard-Grace, & Grumbach, 2014) and person-focused care (Starfield, 2011). Consumer experience research describes how patients prefer continuity of care with the same provider, are unaware that a telehealth option is available, and tend to revert to “how we’ve always done things” when under pressure (Portnoy, Waller, & Elliott, 2020).

Person-focused care recognises the longitudinal relationship between clinician 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 clinic visits, video and phone discussions and consultations, email/secure message correspondence and patient portal interactions.

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 et al., 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 and or phone for consultations, 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.

Therefore, in the context of New Zealand general practice and the Covid19 pandemic, our research question is, “What is the consumer experience of access to telehealth and how do they perceive this mode of care delivery going forward?” This includes the providers’ experience because telehealth in this context consists of real time (synchronous) interactions between consumer and provider, i.e. consultations via video and/or phone (mobile and/or landline).

Research aim and objectives

Aim: To explore the use of video and phone consultations since the 23rd of March 2020 to describe (1) factors (negative and positive) about consumers’ access to telehealth; and (2) perceptions of consumers and providers regarding future use of telehealth in general practice.

Objectives: To achieve the research aim we will

• Conduct a scoping literature review
• Design two questionnaires (consumer and provider) to gather data on the use of video and phone consultations to describe the consumer’s perspective (unknown at this stage) and the providers’ perspectives (to provide context to the consumer’s experiences).
• Use the UTAUT to measure the acceptability of technology (video and phone) 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

Literature review has been conducted to establish what is already known about telehealth in primary care from a consumer perspective.

Survey: We have created two questionnaires (one for consumers and one for primary care providers, i.e. GPs, Nurse Practitioners and Registered Nurses). The questionnaires contain questions related to

• Demographics (age, gender, ethnicity, confidence with computers, computer devices they use, internet access)
• Access to a telehealth consultation (e.g. how they made their appointment and how the
• consultation occurred (e.g. phone or video or combination of both))
• 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 questionnaires are online and are being distributed broadly (using a link and QR code) to recruit as many participants as possible, aiming for 2000 or more responses from consumers and at least 100 responses each from GPs and nurses.

Anyone can participate if they are 18 years or older; have had at least one consultation with their GP, nurse of practice nurse by phone or video after 23 March 2020; are able to understand English well enough to complete the survey; currently reside in New Zealand; and are able to confirm that they have understood what the study is about and agree to participate.

Data analysis: We will statistically analyse the data. This study is both exploratory and descriptive. 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 consumers.

Outputs

We aim to describe consumer experience 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 up-scaled and sustained for ‘business as usual’ that is accessible to all and improves health. We expect to develop a set of guidelines for consumers when choosing to use a telehealth option for primary care, and for primary care professionals for sustained use of telehealth. We will publish the results of this research in peer reviewed journals, present them at conferences, and at primary care service meetings.

Future research plans

This study will provide a foundation for future research that includes in-depth exploration and examination of telehealth use in primary care. Possible future projects would be to gain insights into allied health services’ telehealth use; action research examination of consumer experience relating to digital equity, social and cultural implications, and the co-design of future telehealth initiatives in collaboration with service providers, consumers and industry partners.

Research team

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

Co-investigators: 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), Caroline Lockhart (Massey 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 New Zealand 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

Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high performing primary care. The Annals of Family Medicine, 12(2), 166-171.

Cole, K. (2020, 8 April 2020). ‘We showed them’: Fast and furious changes give hope for better system. New Zealand Doctor. Retrieved from https://www.nzdoctor.co.nz/article/print-archive/weshowed-them-fast-and-furious-changes-give-hope-better-system

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.

Portnoy, J., Waller, M., & Elliott, T. (2020). Telemedicine in the Era of COVID-19. The Journal of Allergy and Clinical Immunology: In Practice

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.

Wright, M., & Mainous III, A. G. (2018). Can continuity of care in primary care be sustained in the modern health system? Australian Journal of General Practice, 47(10), 667-669.

Approved by the Auckland Health Research Ethics Committee on 13 November 2020 for three years, Reference AH2539.