Which visit types in primary care are suitable for Telehealth? A systematic review & design implications for virtual care

Background: The coronavirus (COVID-19) pandemic has significantly impacted primary care, resulting in rapid uptake of Telehealth to prevent community transmission. However, there is limited research on what visit types in primary care are suitable for Telehealth, or whether tasks during in-person consultations in primary care can indeed be supported in Telehealth.

Objective: This thesis investigates which visit types in primary care were reported with Telehealth support during the COVID-19 pandemic, and whether tasks observed during inperson consultations in primary care (e.g., physical examination) are ‘translatable’ to Telehealth.

Methods: This thesis has two phases: a systematic review (PRISMA-compliant and PROSPERO-registered), and a secondary multi-method analysis of in-person GP consultations. • Phase 1 will systematically evaluate recent literature on primary care visit types supported with Telehealth during COVID-19. • Phase 2 will focus on the visit type, identified from the systematic review, that was reported with the greatest number of studies having Telehealth support during COVID-19. By analysing video recordings of in-person GP consultations, we will examine whether those in-person tasks are indeed translatable to Telehealth.

Results:

Our Phase 1 systematic review has identified:

1. Twenty-eight studies, predominately cross-sectional surveys/interviews (61%, 17/28), were included. Seven visit types in primary care were reported with Telehealth support during COVID-19 namely; chronic condition management, medication management, mental health/behavioural management, existing patients (acute or existing concern), new patients (acute or existing concerns), post-test results follow-up, and post-discharge follow-up.

2. Benefits and drawbacks of Telehealth were reported across all visit types, with chronic condition management reporting the greatest support (68%, 19/28).

3. Benefits of Telehealth include improved convenience, focused discussions, and continuity of care despite social distancing. Drawbacks of Telehealth include technical barriers, impersonal interactions, and semi-established reimbursement models.

Our Phase 2 secondary analysis, focusing on Chronic condition management visit, has identified:

1. Nine chronic conditions were observed across 38 GP-Patient consultations, predominately diabetes (39%, 15/38).

2. Out of these 38 consultations, 76% (29/38) featured physical examinations. The average percentage of time spent on physical examination(s) during consultations is low (13.6%, SD=9.4%).

3. A total of 24 clinical tasks were observed across these 38 consultations, where 92% (22/24) were supported by physical artefacts.

4. The average score of a task being translatable to Telehealth is 7/10 (where Score 1= Not amenable to being replicated over Telehealth at this stage, and Score 10 = Easily translatable over Telehealth with almost no additional equipment being required). All tasks observed across chronic condition management during in-person visits were deemed translatable/potentially translatable to Telehealth.

Conclusions: Patients and GPs have demonstrated the wish to continue to use Telehealth beyond COVID-19 due to demonstrated benefits for specific encounters. As primary care worldwide faces the challenge of ways to incorporate Telehealth in the long-run, insights from these two phases will serve to inform recommendations on which visit types are suitable for Telehealth in primary care, what tasks are translatable to Telehealth using current technology, as well as design implications for next-generation of virtual care.