Clinician Decision-Making Around Offering Home Video Telehealth Visits: Qualitative Study.

内容摘要

Use of in-home video telehealth rapidly expanded in response to the COVID-19 pandemic, including at Veterans Affairs (VA), a forerunner in telehealth. Despite this uptick, differences in use by patient age and rurality created a digital divide that persists to this day. While clinicians frequently cite patients' older age and lack of technical skills as barriers to in-home video telehealth, it remains unclear how clinicians decide whether to offer video visits to patients and to what extent these beliefs may hinder offering video visits to older adults. Gathering perspectives from clinician users of in-home video telehealth may illuminate opportunities to ensure continued access to care through solutions such as telehealth. This study aimed to examine clinician decision-making around the offer of in-home video telehealth to understand how interprofessional clinicians determine to whom they offer in-home video telehealth and what factors (organizational, personal, or attitudinal) influence their decision. We conducted a qualitative study by using semistructured interviews. Participants were interprofessional clinicians (N=16) employed by 11 different VA hospitals and included 1 clinical pharmacist, 6 medical doctors, 2 nurse practitioners, 1 occupational therapist, 3 psychologists, 1 physical therapist, 1 speech-language pathologist, and 1 social worker. All the participants had at least some experience using in-home video telehealth from locations across VA (the largest integrated health care system in the United States) and were interviewed over a 6-month period. Interviews focused on clinicians' use of video telehealth and the decision-making process involved in offering in-home video telehealth. We used directed content analysis with a rapid analytic approach, given the time-pressured nature of our project. This study revealed that clinician decision-making around offering in-home video visits is complex and influenced by several domains, namely, (1) clinician factors, including experience with video and perceived benefits of video; (2) appointment factors, including the visit's clinical goal; (3) clinician-reported patient factors, including age and willingness to try video; (4) patient social context, including caregiver availability; (5) geographical factors, such as availability of reliable high-speed internet and patient distance from the medical center; and (6) health system factors, including technical support and clinician ability to work from home. Access to in-home video telehealth may be facilitated by clinician familiarity and confidence with telehealth technology, strategies to improve patients' technical skills, and support for caregivers. Infrastructure also plays an important role, including device availability, broadband reliability, and clear protocols for matching services to video visits. Findings highlight the importance of clinician competency in telehealth, patient and caregiver digital readiness, and a supportive technology infrastructure to equitable in-home video care. In addition, improved guidance for specific clinical services and awareness of potential biases may enable consistent, accessible telehealth delivery for older adults and medically complex populations.