What a Pandemic Has Taught Us 杏吧原创 the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia

Petrie S, Carson D, Peters PA, Hurtig A-K, LeBlanc M, Simpson H, Barnabe J, Young M, Ostafichuk M, Hodge H, Glademan J, Smale M, & M Gonzalez Garcia. (2021) 鈥淲hat a Pandemic Has Taught Us 杏吧原创 the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.鈥� Frontiers in Public Health. 9: 768624 .

Abstract

The COVID-19 pandemic coincided with a multi-national federally funded research project examining the potential for health and care services in small rural areas to identify and implement innovations in service delivery. The project has a strong focus on electronic health (eHealth) but covers other areas of innovation as well. The project has been designed as an ethnography to prelude a realist evaluation, asking the question under what conditions can local health and care services take responsibility for designing and implementing new service models that meet local needs? The project had already engaged with several health care practitioners and research students based in Canada, Sweden, Australia, and the United States. Our attention is particularly on rural communities with fewer than 5,000 residents and which are relatively isolated from larger service centres. Between March and September 2020, the project team undertook ethnographic and auto-ethnographic research in their own communities to investigate what the service model responses to the pandemic were, and the extent to which local service managers were able to customize their responses to suit the needs of their communities. An initial program theory drawn from the extant literature suggested that 鈥渟uccessful鈥� response to the pandemic would depend on a level of local autonomy, 鈥渁bsorptive capacity,*鈥� strong service-community connections, an 鈥渁nti-fragile鈥犫�� approach to implementing change, and a realistic recognition of the historical barriers to implementing eHealth and other innovations in these types of rural communities. The field research in 2020 has refined the theory by focusing even more attention on absorptive capacity and community connections, and by suggesting that some level of ignorance of the barriers to innovation may be beneficial. The research also emphasized the role and power of external actors to the community which had not been well-explored in the literature. This paper will summarize both what the field research revealed about the capacity to respond well to the COVID-19 challenge and highlight the gaps in innovative strategies at a managerial level required for rapid response to system stress.

*Absorptive Capacity is defined as the ability of an organization (community, clinic, hospital) to adapt to change. Organizations with flexible capacity can incorporate change in a productive fashion, while those with rigid capacity take longer to adapt, and may do so inappropriately.

鈥燗ntifragility is defined as an entities’ ability to gain stability through stress. Biological examples include building muscle through consistent use, and bones becoming stronger through subtle stress. Antifragility has been used as a guiding principle in programme implementation in the past.

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Hondonga T, Sendanyoye C, Mahling A, Sourial M, Trto S, & PA Peters. (2021). 鈥淩eport: Potential for eHealth in rural and remote follow-up care.鈥� Spatial Determinants of Health Lab, 杏吧原创 University: Ottawa ON. DOI: 10.22215/sdhlab/2021.1.

A full PDF of this report is also available.

Rural and remote communities in Canada and Australia are disproportionally affected by barriers when accessing healthcare. Barriers include, but are not limited to:  lengthy travel distances, inefficient communication between healthcare teams, and client disengagement in follow-up care (1鈥�5).  These barriers are notably evident when seeking access to more specialized health services (1). While, Canada and Australia have implemented electronic health (eHealth) technologies to mitigate issues of access to specialized healthcare services in rural and remote areas, their routine use in follow-up care has not been fully implemented (6,7).

eHealth can be described as any technology that is used to deliver health services electronically (8). It is available in several mediums such as: mobile health, telehealth, and electronic health records. Mobile health is a medium in which healthcare services are delivered via mobile technologies such as smartphones, tablets, and wearables (9,10). Additionally, telehealth involves the use of telephones or video-conferencing technologies to correspond with clients, or remote client monitoring technologies to collect data on their clients鈥� health (6). Lastly, electronic health records are a form of eHealth technologies whereby health care providers securely store and share health information of clients (11,12).

eHealth technologies have been promoted in rural and remote communities as they have demonstrated the potential to dissolve barriers of access to healthcare services, facilitate efficient health service delivery, improve client care, and health outcomes in hard-to-reach areas (13). However, further research into the advantages and disadvantages of eHealth services in rural and remote communities is warranted. Thus, this report aims to identify the advantages and disadvantages of eHealth services among service users in rural and remote communities in Australia and Canada; specifically, examining the role eHealth plays in follow-up care, client experiences using eHealth as an alternative to face-to-face appointments, and suggestions for future implementation.

KEY FINDINGS

ADVANTAGES AND DISADVANTAGES

This review identified five advantages and four disadvantages of eHealth services for follow-up care for service users in rural and remote communities in Canada and Australia (Figure 1). eHealth services enabled healthcare team members to share information about diagnosis, test findings, imaging results, and medications with clients in a timely matter, avoiding unnecessary referrals and long-wait times for follow-up appointments (2,3,5). Consequently, physicians found eHealth facilitated improved client education and client self-management (2鈥�5). eHealth services removed distance as a barrier to accessing health services. However, a major disadvantage of eHealth services included the inability to complete physical assessments (20,21). Moreover, clients reported a concerns about online privacy regarding the sharing of personal health information (14,16鈥�19). Clients also felt that in some instances there was no need for follow-up appointments (16). Lastly, physicians reported non-relevant conversations took up extra time during appointments (16).

FUTURE CONSIDERATIONS

Although e-visits have proven to be beneficial in certain medical disciplines, in other fields they were deemed challenging (e.g., post-operative care). Therefore, it is imperative that future research analyzes how eHealth follow-up care can be implemented efficiently across various medical specialties. Logistical issues related to the availability of an electronic device and internet reliability remain common limitations. This issue may be addressed by an established eHealth site in a rural community, allowing e-visits for clients to save time and money on travel. Furthermore, alleviating client and provider privacy concerns is crucial for the sustainability of eHealth interventions. Promotion of secure and protected systems can offer clients reassurance on the safety and security of their private health information. In summary, a strong evidence-base is required centering these key priority areas to better inform policy and implementation of eHealth services in rural and remote communities.

METHODS

This report is based on a structured scoping review undertaken to identify the scope of research on the role eHealth plays in follow-up care in rural and remote regions of Canada and Australia. The identification of appropriate literature for this review followed Arksey and O鈥橫alley鈥檚 five stage process, beginning with: 1) defining the key terms used in the search engines; 2) identification of relevant studies; 3) study selection based on a set of inclusion and exclusion criterion; 4) charting the data; and, 5) collating, summarizing, synthesizing and reporting on the findings of the articles (22).  The scoping review identified 18 primary articles that met inclusion criteria. Articles focused on the role of eHealth, specifically barriers, enablers, and the utility of electronic health services in follow-up care.

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Barnabe J., Petrie S., & P. Peters. 2020. Virtual Triage and Teletriage in Rural Canada and Australia: A Rapid Review. Spatial Determinants of Health Lab Ottawa, ON. doi: 10.22215/sdhlab/2020.2.

A complete PDF is also available for download.

Public Health Topic

Health care services and healthcare infrastructure in rural areas is continuously adapting in to meet the needs of rural and remote populations. Rural populations are unique and diverse, where there is a diversity of individuals within communities, and an equivalent diversity between communities. There are documented differences in health behaviours, health literacy, perceived health, and health outcomes between and within rural regions and rural communities. While geographic accessibility is often considered the primary driver, differences go beyond distance and include elements of demographic change, economic restructuring, and continued reductions in health and services.

The features of rural health care delivery are further underscored in the wake of the COVID-19 global health pandemic, a rapidly evolving situation which is undoubtedly putting pressure on already strained rural emergency departments (ED). In attempts to alleviate strain on front-line health provision and ensure the safety of the public, many healthcare facilities have rapidly implemented or have scaled-up eHealth solutions such as virtual triage and urgent care systems. These are virtual (virtual triage) or telephone systems (teletriage) in which patients can contact a physician or other healthcare professional who will guide them to appropriate care. The objective of these interventions is most often to reduce the overall number of in-person visits to EDs, potentially tackling ED overcrowding and misuse.

Current Knowledge

Overcrowding, long wait times, and lack of resources is a persistent issue in countries with publicly guaranteed health systems, with EDs being disproportionately affected. This is especially prevalent in rural Canada and Australia, where rural healthcare access and resources are limited. Although it is a complex problem, one of the main contributing factors to this pressure is the growing number of patients presenting to EDs with non-urgent complaints, many of whom are seeking primary care. Although seeking non-urgent care from the emergency department is seen as inappropriate to health system planners, it is often the only choice rural patients have. Over 4.7 million Canadians do not have a primary care provider and only 25% report they have a usual place of care such as an urgent care clinic, a luxury that is hard to come by in rural areas. A similar reality is seen in Australia, where access to general practitioners in regional or remote areas is limited, with many reporting visiting ED鈥檚 because a general practitioner was not available.

Initiatives such as telehealth and virtual visits have been suggested to bridge the gaps seen in rural healthcare and are part of broader eHealth initiatives that include electronic medical records, remote health monitoring, and other electronic health technologies. Identified benefits of using eHealth services for primary care provision include reducing the burdens that come with travelling long distances, increasing access to care, and cost savings across various domains. Despite perceived benefits, implementation is often non-existent, difficult, or slow. Cost, technological issues, and slow acceptance by providers is a recurring issue for successful long-term eHealth implementation.

Teletriage and virtual triage are eHealth initiatives proposed to mitigate rural healthcare gaps. Teletriage is the use of telephone conferencing services to guide patients to appropriate care based on patient presentation, the urgency of the condition, and the policy of the organization. Virtual triage is where secure video connections are integrated with secure voice. Various telephone triage initiatives have been slowly developed and implemented across Canada, and Australia. Despite the evidence of success with teletriage, virtual and video integration with these systems has been met with resistance, with few adopting it. However, amid the COVID-19 pandemic, Canadian and Australian healthcare providers have been advised to provide virtual care where possible, resulting in the rapid creation and scaling up of exiting teletriage platforms and integration of virtual triage.

Key Evidence

• Telephone triage (teletriage) has been slow to expanded in Canada and Australia.
• Teletriage is effective, safe, with high levels of reported patient satisfaction.
• Teletriage can provide an alternative to primary acute care when not available.
• Virtual triage is recent with most new platforms implemented due to the COVID-19 pandemic.
• Integration of video creates multiple layers of care, further improving effectiveness.
• Many of the limitations of tele- and virtual triage are related to existing inequalities in rural areas.
• Tele- and virtual systems can be effective at deferring patients from emergency departments.

Policy Recommendations

• Platforms need to be flexible, responsive, and tailored to regional circumstances
• Successful platforms are locally-based
• Leadership across stakeholders is essential to success
• Platforms are partnerships and collaborations
• Advertising and messaging are important
• Platforms use and create data, which must be analysed continuously

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Morris S, Stevens S, Leblanc M, Petrie S, Carson DB & PA Peters (2019). Infographic: Telepediatrics in Rural and Remote Regions. Spatial Determinants of Health Lab, 杏吧原创 University: Ottawa, ON. DOI:10.22215/sdhlab/kt/2019.4

A high-quality PDF of this infographic is available for download.

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Leblanc M, Petrie S, Carson DB, Paskaran S, & PA Peters. (2019) Patient and Provider Perspectives on Rural eHealth Interventions in Canada and Australia. Spatial Determinants of Health Lab, 杏吧原创 University: Ottawa, ON. DOI:10.22215/sdhlab/2019.3

A high-quality PDF of this report is available for download.

Although health care is widely accessible in most developed countries, rural areas often struggle to adequately meet health care needs. Challenges in accessing and receiving adequate health care introduce large variations in disease levels, level of treatment, life expectancy, and overall health status for rural populations.

eHealth, or electronic health, defined here as any electronic medium used to access health services, is a method used to bridge the gap between rural and urban centres to improve health care access. Including the above definition, eHealth also includes any technology designed to improve efficiencies and reduce costs in relation to health care. By providing a comprehensive overview of feedback from past interventions, policy-makers and program developers can develop strategies to improve the implementation and the use of eHealth technologies.

Although eHealth has been reported as a favourable method to increase access to health care, users report many disadvantages that warrant improvement. Updated technology, increased IT support and training, and regular meetings between urban and rural providers can improve the uptake of telemedicine in rural communities. Providers and stakeholders should recognize specific instances in which eHealth may not be the best option to deliver care, such as in mental health cases where face-to-face contact is important in treatment. The highly reported benefits of decreased travel, cost, and increased access to care indicate that the advantages of eHealth outweigh the disadvantages and will be an effective means to improve access to health care for rural areas.

Based on reviewed literature, eHealth is a favourable method to increase access to care, as denoted by levels of positive feedback from patients and providers. Although negative perspectives are still pervasive, effectively quantifying them is difficult.

The primary reported benefits of eHealth include decreased travel time, time/cost saving, and increased access to services, followed by effective technology, increased support, and increased patient involvement.

Decreased travel time was reported most from both patients and providers, regardless of the type of eHealth technology used. Before eHealth was introduced, travelling to and from appointments was an inconvenience; it took time away from work, from family, and from community involvement. The travel time and the travel itself can have negative effects on health, where patients can be exhausted from travel and may take longer to recover.

eHealth allowed rural communities to access specialist services otherwise unavailable in the area, enabling health issues to be identified and addressed earlier. The use of technology has been shown repeatedly to save time and money, for both patients and for the health system. eHealth increased primary care levels and follow-up rates, which in turn reduced inappropriate referrals or transfers to urban centres. After using eHealth, rural health care providers reported an increased level of confidence and a broader skill set by observing specialists. Regular contact with specialists also allowed rural practitioners to seek help when necessary, decreasing isolation and creating a network of providers to provide support. In some instances, patients also felt more comfortable disclosing information through technology, which facilitated communication with providers.

The primary disadvantages of telehealth identified were technological issues, lack of face-to-face contact, limited IT training, lack of coordination, confidentiality, and system cost. Technological issues stemmed from inadequate technology, such as insufficient broadband connection, and inadequate IT support or training.

Many successful programs implemented technology training programs and on-site IT support to facilitate the transition to eHealth for patients and providers. Preference for face-to-face contact varied among individuals, specialties, and situations. Providers identified specific instances in which it would not be appropriate to use eHealth, such as in feeding assessments in speech pathology. They also felt it was difficult to break bad news to patients using technology, or to note the subtle cues that could help form a more complete, accurate diagnosis. The importance of effective coordination between urban and rural providers introduced challenges, especially if the two physicians had differing opinions regarding treatment or delivery of care. The disagreements would confuse patients, leading to distrust of both providers. In some cases, the specialist was unaware of services or resources available in rural areas, which created unrealistic patient expectations. To facilitate communication, both providers should be available and easily contactable during consultations.

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Aboukarr S, LeBlanc M, Petrie S, Carson DB, Paskaran S, & PA Peters. (2019) Report: Best Practices for Rural eMental Health. Spatial Determinants of Health Lab, 杏吧原创 University: Ottawa, ON. DOI:10.22215/sdhlab/2019.2

A high-quality PDF of this report is available for download.

The more 鈥渞ural鈥� or 鈥渞emote鈥� a community, access to mental health services decreases. By mitigating barriers and promoting enablers, successful eMental health integration can increase access to mental health services for rural residents.

eMental health aims to bridge the gap between rural and urban mental health services by introducing electronic methods such as teleconferencing or video conferencing for psychological services, virtual referral to psychiatrists, and sharing of electronic records. Successful integration of the technology remains a challenging task, with key actors, enablers, and barriers all influencing its success.

Rural patients and health care providers identify advantages and disadvantages in using eMental health. Health system users report increased access to care, decreased travel time, increased support, decreased hospital transfers, and stronger interpersonal relationships as advantages. Disadvantages include technical problems, privacy and confidentiality concerns, physical limitations, administrative difficulties, and inadequate health care provision.

Although patients and providers note these benefits or drawbacks based on their personal experiences, the success of an eMental health program may need to be reviewed on a larger scale. There is an association between modifiable systemic barriers and satisfaction levels, based on feedback from patients and providers. By focusing on the larger-scale enablers and barriers that underly the frustrations and successes that patients and providers experience using eMental health, disadvantages can be mitigated, and advantages can be amplified.

Primary systemic barriers to the success of telemedicine include inadequate technical equipment, funding/resource constraints, and resistance from health care providers, patients, and families. Enablers of the system include pre-established environment and care procedures, program promotion and training, regular contact among health care providers, technical improvements and support, organized administration, and planning procedures.

Technological issues often impede the successful uptake of eMental health in communities. Patients and providers report frustration with technology, including delayed speech and movement, sound echoes, and inadequate internet access. Rural areas that experience more technical problems report lower levels of utilization merely due to technological issues. If the infrastructure in which the technology operates is optimized, then the level of acceptance and integration of telemedicine into mental health services can be improved.

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