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Real-world implementation of video outpatient consultations at macro, meso, and micro levels: Mixed-method study

Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. Objective: The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model. Methods: A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). Results: When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Conclusions: Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework (Preprint)

BACKGROUND COVID-19 has thrust video consulting into the limelight, as health care practitioners worldwide shift to delivering care remotely. Evidence suggests that video consulting is acceptable, safe, and effective in selected conditions and settings. However, research to date has mostly focused on initial adoption, with limited consideration of how video consulting can be mainstreamed and sustained. OBJECTIVE This study sought to do the following: (1) review and synthesize reported opportunities, challenges, and lessons learned in the scale-up, spread, and sustainability of video consultations, and (2) identify transferable insights that can inform policy and practice. METHODS We identified papers through systematic searches in PubMed, CINAHL, and Web of Science. Included articles reported on synchronous, video-based consultations that had spread to more than one setting beyond an initial pilot or feasibility stage, and were published since 2010. We used the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework to synthesize findings relating to 7 domains: an understanding of the health condition(s) for which video consultations were being used, the material properties of the technological platform and relevant peripherals, the value proposition for patients and developers, the role of the adopter system, organizational factors, wider macro-level considerations, and emergence over time. RESULTS We identified 13 papers describing 10 different video consultation services in 6 regions, covering the following: (1) video-to-home services, connecting providers directly to the patient; (2) hub-and-spoke models, connecting a provider at a central hub to a patient at a rural center; and (3) large-scale top-down evaluations scaled up or spread across a national health administration. Services covered rehabilitation, geriatrics, cancer surgery, diabetes, and mental health, as well as general specialist care and primary care. Potential enablers of spread and scale-up included embedded leadership and the presence of a telehealth champion, appropriate reimbursement mechanisms, user-friendly technology, pre-existing staff relationships, and adaptation (of technology and services) over time. Challenges tended to be related to service development, such as the absence of a long-term strategic plan, resistance to change, cost and reimbursement issues, and the technical experience of staff. There was limited articulation of the challenges to scale-up and spread of video consultations. This was combined with a lack of theorization, with papers tending to view spread and scale-up as the sum of multiple technical implementations, rather than theorizing the distinct processes required to achieve widespread adoption. CONCLUSIONS There remains a significant lack of evidence that can support the spread and scale-up of video consulting. Given the recent pace of change due to COVID-19, a more definitive evidence base is urgently needed to support global efforts and match enthusiasm for extending use.

Clinical guidelines and the pursuit of reducing epistemic uncertainty. An ethnographic study of guideline development panels in three countries

Purpose: To explore, from a philosophy of knowledge perspective, the contribution of the guideline development process to reducing epistemic uncertainty in clinical decision-making – defined as the challenge of applying evidence to patients, dealing with conflicting information and determining the level of confidence in a medical conclusion. Methods: Longitudinal ethnographic study of national guideline development panels. Fieldnotes were collected from 19 panel meetings in UK, Netherlands and Norway (~120 h of observation) between September 2016 and February 2019. Draft guidelines, review protocols and background material were collated (~200 documents). Data were analyzed thematically to gain familiarity and then theorized using concepts of knowledge development and use and clinical decision-making. Results: Guideline development panels in all three countries wrestled with epistemic tensions – notably between the desire to “purify” an assumed external truth (for example by limiting included evidence to high-quality randomized controlled trials) and a more pragmatic and pluralist approach that drew on a wider range of evidence including qualitative research, real-world data, clinical experience and patient testimony. Detailed analysis of the process by which particular guideline recommendations were constructed allowed us to draw out the implications of these tensions for guideline users in clinical practice. Conclusion: Guideline development panels apply multiple – often conflicting – understandings of knowledge, inference and truth in an attempt to reduce epistemic uncertainty. Guidelines makers, clinicians, scientists and students should engage critically and reflexively with the philosophical assumptions that underpin guideline development and inductive inference to build capability to deal with clinical complexity.

Management of post-acute covid-19 in primary care

How covid-19 spreads: Narratives, counter narratives, and social dramas

Covid-19: A remote assessment in primary care

Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction (Preprint)

BACKGROUND Video-mediated clinical consultations offer potential benefits over conventional face-to-face in terms of access, convenience, and sometimes cost. The improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. However, questions remain regarding clinical quality and safety. Video-mediated consultations are sometimes criticized for being not as good as face-to-face, but there has been little previous in-depth research on their interactional dynamics, and no agreement on what a good video consultation looks like. OBJECTIVE Using conversation analysis, this study aimed to identify and analyze the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. METHODS We conducted an in-depth analysis of the clinician-patient interaction in a sample of video-mediated consultations and a comparison sample of face-to-face consultations drawn from 4 clinical settings across 2 trusts (1 community and 1 acute care) in the UK National Health Service. The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer, and heart failure patients), 28 matched audio recordings of face-to-face consultations, and fieldnotes from before and after each consultation. We also conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). RESULTS Patients had been selected by their clinician as <i>appropriate</i> for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases, a relative) to simultaneously follow instructions and manipulate technology (eg, camera) to make it possible for the clinician to see and hear adequately. CONCLUSIONS A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinicians and patients can work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via a video link. INTERNATIONAL REGISTERED REPORT RR2-10.2196/10913

Authors' reply to Ward

The NASSS framework for ex post theorisation of technology-supported change in healthcare: Worked example of the TORPEDO programme

Background: Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework was developed to study unfolding technology programmes in real time- A nd in particular to identify and manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. Methods: We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic Decision Support) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology (HealthTracker) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDO dataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, videotaped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. Results: Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: The nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians' experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. Conclusion: The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes, failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.

Personalized Medicine, Disruptive Innovation, and “Trailblazer” Guidelines: Case Study and Theorization of an Unsuccessful Change Effort

Policy Points For complex reasons, the promise of “precision medicine” based on molecular pathways remains unrealized for many conditions. Clinical practice guidelines (theoretically, at least) can act as “trailblazers” to introduce tests and treatments that reflect precision medicine discoveries. We describe a detailed case study from the United Kingdom in which such an attempt was (so far) unsuccessful and show how this case provides generalizable lessons. Policymakers should be wary of using clinical practice guidelines as the sole, or even the primary, lever for introducing precision medicine. Context: Precision medicine, which addresses underlying molecular mechanisms of disease, depends on new technologies that measure specific biomarkers, leading (it is anticipated) to more accurate diagnosis, patient stratification, and tailored treatment. These technologies can be disruptive—that is, they make possible, and often require, radical changes to clinical practice and service organization—thereby improving quality, safety, or efficiency of care. Clinical practice guidelines may act as “trailblazers,” introducing and legitimizing novel technologies and practices. Methods: We describe a case study of an attempt by academic researchers to radically change asthma management in the United Kingdom using a precision medicine biomarker (fractional exhaled nitric oxide, FeNO), measured using a portable breath device. We collected a wide-ranging data set that included more than 100 documents, 61 interviews, and 150 hours of ethnographic observation, and we analyzed it using technology-enhanced strong structuration theory (TESST). Findings: Our study describes a so-far unsuccessful attempt by academic respiratory medicine researchers to pave the way for a precision medicine approach to asthma using a government-endorsed national guideline. These researchers considered asthma management, especially in primary care, to be characterized by overdiagnosis and poor tailoring of treatment; engaged a national guideline development body in an effort to fix this problem; and ensured that the guideline required primary care clinicians to use FeNO technology for diagnosis and monitoring. However, clinicians working outside the tertiary referral centers did not accept, or agree to enact, the vision of precision medicine inscribed in the guideline—for multiple professional, operational, and economic reasons. Conclusions: “Trailblazer” guidelines, in which new technologies are recommended, may succeed as catalysts of change only in a limited way for interested individuals and groups. In the absence of a wider program of professionally led and adequately resourced change efforts, such guidelines will lack meaning, legitimacy, and authority among intended users and may be strongly resisted.

Physical examinations via video? Qualitative study of video examinations in heart failure, using conversation analysis (Preprint)

BACKGROUND Video consultations are increasingly seen as a possible replacement for face-to-face consultations. Direct physical examination of the patient is impossible, but a limited examination may be undertaken via video (e.g. using visual signals, or asking a patient to press their lower legs and assess fluid retention). Little is currently known about what such video examinations involve. OBJECTIVE To explore the opportunities and challenges of remote physical examination with patients with heart failure using video-mediated communication technology. METHODS Seven video consultations (using FaceTime) between patients with heart failure and their community-based specialist nurses were video-recorded with consent. We used conversation analysis to identify the challenges of remote physical examination over video and the verbal and non-verbal communication strategies used to address them. RESULTS Apart from a general visual overview, remote physical examination in heart failure patients was restricted to assessing fluid retention (by the patient or relative feeling for leg oedema), blood pressure and pulse rate and rhythm (using a self-inflating blood pressure monitor incorporating an irregular heart beat indicator, and put on by the patient or relative-) and oxygen saturation (using a finger clip device). In all seven cases, one or more of these examinations were accomplished via video, generating accurate biometric data for assessment by the clinician. However, video examinations proved challenging for all involved. Participants (patients, clinicians and, sometimes, relatives) needed to collaboratively negotiate three recurrent challenges: (i) adequate design of instructions to guide video examinations (with nurses required to explain tasks using lay language, and checking instructions were followed); (ii) accommodation of the patient’s desire for autonomy (on the part of nurses and relatives) in light of opportunities for involvement in their own physical assessment; and (iii) doing the physical examination while simultaneously making it visible to the nurse (with patients and relatives needing adequate technological knowledge in order to operate a device and make the examination visible to the nurse, as well as basic biomedical knowledge to follow nurses’ instructions). Nurses remained responsible for making a clinical judgment of the adequacy of the examination and the trustworthiness of the data. In sum, despite significant challenges, selected participants in heart failure consultations managed to successfully complete video examinations. CONCLUSIONS Video examinations are possible in the context of heart failure services. However, they are limited, time-consuming and challenging for all involved. Guidance and training are needed to support roll out of this new service model, along with research to understand if the challenges identified are relevant to different patients and conditions and how they can be successfully negotiated.

Remote care in UK general practice: baseline data on 11 case studies

Background: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs. Methods: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data. Results: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features—notably system-level stressors such as high workload and staff shortages, and UK’s technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the ‘digital front door’ (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts. Conclusions: General practices’ responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Orthodoxy, illusio, and playing the scientific game: a Bourdieusian analysis of infection control science in the COVID-19 pandemic

Background: Scientific and policy bodies’ failure to acknowledge and act on the evidence base for airborne transmission of SARS-CoV-2 in a timely way is both a mystery and a scandal. In this study, we applied theories from Bourdieu to address the question, “How was a partial and partisan scientific account of SARS-CoV-2 transmission constructed and maintained, leading to widespread imposition of infection control policies which de-emphasised airborne transmission?”. Methods: : From one international case study (the World Health Organisation) and four national ones (UK, Canada, USA and Japan), we selected a purposive sample of publicly available texts including scientific evidence summaries, guidelines, policy documents, public announcements, and social media postings. To analyse these, we applied Bourdieusian concepts of field, doxa, scientific capital, illusio, and game-playing. We explored in particular the links between scientific capital, vested interests, and policy influence. Results: : Three fields—political, state (policy and regulatory), and scientific—were particularly relevant to our analysis. Political and policy actors at international, national, and regional level aligned—predominantly though not invariably—with medical scientific orthodoxy which promoted the droplet theory of transmission and considered aerosol transmission unproven or of doubtful relevance. This dominant scientific sub-field centred around the clinical discipline of infectious disease control, in which leading actors were hospital clinicians aligned with the evidence-based medicine movement. Aerosol scientists—typically, chemists, and engineers—representing the heterodoxy were systematically excluded from key decision-making networks and committees. Dominant discourses defined these scientists’ ideas and methodologies as weak, their empirical findings as untrustworthy or insignificant, and their contributions to debate as unhelpful. Conclusion: The hegemonic grip of medical infection control discourse remains strong. Exit from the pandemic depends on science and policy finding a way to renegotiate what Bourdieu called the ‘rules of the scientific game’—what counts as evidence, quality, and rigour.

Developing services for long COVID: lessons from a study of wounded healers

Persistent symptoms lasting longer than 3 weeks are thought to affect 10–2 0% of patients following SARS-CoV-2 infection. No formal guidelines exist in the UK for treating patients with long COVID and services are sporadic and variable, although additional funding is promised for their development. In this study, narrative interviews and focus groups are used to explore the lived experience of 43 healthcare professionals with long COVID. These individuals see the healthcare system from both professional and patient perspectives, thus represent an important wealth of expertise to inform service design. We present a set of co-designed quality standards, highlighting equity and ease of access, minimal patient care burden, clinical responsibility, a multidisciplinary and evidence-based approach, and patient involvement; and we apply these to propose a potential care pathway model that could be adapted and translated to improve care of patients long COVID.

Direct and indirect evidence of efficacy and safety of rapid exercise tests for exertional desaturation in Covid-19: A rapid systematic review

Background: Even when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of different rapid tests for exertional desaturation and draw on this evidence base to provide guidance in the context of acute COVID-19. Main research questions 1. What exercise tests have been used to assess exertional hypoxia at home or in an ambulatory setting in the context of Covid-19 and to what extent have they been validated?2. What exercise tests have been used to assess exertional hypoxia in other lung conditions, to what extent have they been validated and what is the applicability of these studies to acute Covid-19? Method: AMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. A protocol for the review was published on the Medrxiv database. Results: Of 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-minute sit-to-stand test [1MSTST] with reference to the 6-minute walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%), and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). Heterogeneity of study design precluded meta-analysis. Discussion: Exertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. A stronger evidence base exists for the diagnostic accuracy of the 1MSTST in chronic long term pulmonary disease, the relative intensity of this test may raise safety concerns in remote consultations or unstable patients. The less strenuous 40-step walk test should be urgently evaluated.

Group clinics for young adults living with diabetes in an ethnically diverse, socioeconomically deprived population: mixed-methods evaluation

Background: Our research was based on the expressed need to evaluate the potential for group clinics to enhance care within the NHS for people with long-term conditions. Objectives: We aimed to explore the scope, feasibility, impact and potential scalability of group clinics for young adults with diabetes who have poor experiences of care and clinical outcomes. We applied a participatory approach to the entire research process, where appropriate. Setting: Four NHS trusts delivering diabetes care to young adults in ethnically diverse and socioeconomically deprived communities. Participants: We involved 135 young adults as participants in our research (73 at two intervention sites and 62 at two control sites). Methods: A realist review synthesised existing evidence for group clinics to understand ‘what works, for whom, under what circumstances’. Using the realist review findings and a scoping exercise, we used co-design to develop a model of group clinic-based care, which we then implemented and evaluated using primarily qualitative methods, with quantitative and costs analyses to inform future evaluations. Results: Young adults reported positive experiences from the group clinics. However, across the group clinics delivered, only one-third (on average) of those invited to specific clinics attended, despite substantial efforts to encourage attendance, and only 37 out of 73 (51%) participants attended any group clinics. Social learning helped the acquisition of new knowledge and normalisation of experiences. Group clinics met previously unreached emotional needs, and the relationships that formed between young adults, and between them and the staff facilitating the clinics, were key. Clinical staff delivered the clinics using a facilitatory approach, and a youth worker helped to ensure that the care model was developmentally appropriate. Existing organisational structures presented substantial challenges to the delivery of group clinics, and there was considerable hidden work required by the staff delivering them. Group clinics may augment one-to-one care but do not necessarily replace it. The average cost of each group clinic, per participant, was £127–58. Limitations: Engagement in co-design and the research process and participation in the group clinics was challenging, and limited our quantitative data analysis. These limitations had implications for the fidelity of the intervention and generalisability of our findings. During the research, we established that group clinics would not replace existing care, and that further work is required to understand the theoretical base of ‘blended’ models of care, and the potential of digital offers, before a definitive evaluation (a cluster-randomised trial) can be designed. Conclusions: Our findings show that young adults with diabetes, including those in deprived and ethnically diverse settings, have positive experiences of group-based care, and it may augment existing one-to-one care. However, engagement with group-based care is challenging despite the participatory design. Future work: Future research is needed to develop the group clinic model prior to definitive evaluation. Study registration: This study is registered as CRD42017058726 and ISRCTN83599025.

Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review

Objectives In the context of the Covid-19 pandemic, to identify the range of filtering respirators that can be used in patient care and synthesise evidence to guide the selection and use of different respirator types. Design Comparative analysis of international standards for filtering respirators and rapid review of their performance and impact in healthcare. Data sources Websites of international standards organisations, Medline and EMBASE (final search 11 th May 2020), with hand-searching of references and citations. Study selection Guided by the SPIDER tool, we included studies whose sample was healthcare workers (including students). The phenomenon of interest was respirators, including disposable and reusable types. Study designs including cross-sectional, observational cohort, simulation, interview and focus group. Evaluation approaches included test of respirator performance, test of clinician performance or adherence, self-reported comfort and impact, and perceptions of use. Research types included quantitative, qualitative and mixed methods. We excluded studies comparing the effectiveness of respirators with other forms of protective equipment. Data extraction, analysis and synthesis Two reviewers extracted data using a template. Suitability for inclusion in the analysis was judged by two reviewers. We synthesised standards by tabulating data according to key criteria. For the empirical studies, we coded data thematically followed by narrative synthesis. Results We included relevant standards from 8 authorities across Europe, North and South America, Asia and Australasia. 39 research studies met our inclusion criteria. There were no instances of comparable publications suitable for quantitative comparison. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit-testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators. Conclusion A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to the delivery of care.

Studying technology use as social practice: The untapped potential of ethnography

Information and communications technologies (ICTs) in healthcare are often introduced with expectations of higher-quality, more efficient, and safer care. Many fail to meet these expectations. We argue here that the well-documented failures of ICTs in healthcare are partly attributable to the philosophical foundations of much health informatics research. Positivistic assumptions underpinning the design, implementation and evaluation of ICTs (in particular the notion that technology X has an impact which can be measured and reproduced in new settings), and the deterministic experimental and quasi-experimental study designs which follow from these assumptions, have inherent limitations when ICTs are part of complex social practices involving multiple human actors. We suggest that while experimental and quasi-experimental studies have an important place in health informatics research overall, ethnography is the preferred methodological approach for studying ICTs introduced into complex social systems. But for ethnographic approaches to be accepted and used to their full potential, many in the health informatics community will need to revisit their philosophical assumptions about what counts as research rigor. © 2011 Greenhalgh and Swinglehurst; licensee BioMed Central Ltd.

Ethnographic study of ICT-supported collaborative work routines in general practice

Background. Health informatics research has traditionally been dominated by experimental and quasi-experimental designs. An emerging area of study in organisational sociology is routinisation (how collaborative work practices become business-as-usual). There is growing interest in the use of ethnography and other in-depth qualitative approaches to explore how collaborative work routines are enacted and develop over time, and how electronic patient records (EPRs) are used to support collaborative work practices within organisations. Methods/design. Following Feldman and Pentland, we will use 'the organisational routine' as our unit of analysis. In a sample of four UK general practices, we will collect narratives, ethnographic observations, multi-modal (video and screen capture) data, documents and other artefacts, and analyse these to map and compare the different understandings and enactments of three common routines (repeat prescribing, coding and summarising, and chronic disease surveillance) which span clinical and administrative spaces and which, though 'mundane', have an important bearing on quality and safety of care. In a detailed qualitative analysis informed by sociological theory, we aim to generate insights about how complex collaborative work is achieved through the process of routinisation in healthcare organisations. Discussion. Our study offers the potential not only to identify potential quality failures (poor performance, errors, failures of coordination) in collaborative work routines but also to reveal the hidden work and workarounds by front-line staff which bridge the model-reality gap in EPR technologies and via which "automated" safety features have an impact in practice. © 2010 Swinglehurst et al; licensee BioMed Central Ltd.

What matters to older people with assisted living needs? A phenomenological analysis of the use and non-use of telehealth and telecare

Telehealth and telecare research has been dominated by efficacy trials. The field lacks a sophisticated theorisation of [a] what matters to older people with assisted living needs; [b] how illness affects people's capacity to use technologies; and [c] the materiality of assistive technologies. We sought to develop a phenomenologically and socio-materially informed theoretical model of assistive technology use. Forty people aged 60-98 (recruited via NHS, social care and third sector) were visited at home several times in 2011-13. Using ethnographic methods, we built a detailed picture of participants' lives, illness experiences and use (or non-use) of technologies. Data were analysed phenomenologically, drawing on the work of Heidegger, and contextualised using a structuration approach with reference to Bourdieu's notions of habitus and field. We found that participants' needs were diverse and unique. Each had multiple, mutually reinforcing impairments (e.g. tremor and visual loss and stiff hands) that were steadily worsening, culturally framed and bound up with the prospect of decline and death. They managed these conditions subjectively and experientially, appropriating or adapting technologies so as to enhance their capacity to sense and act on their world. Installed assistive technologies met few participants' needs; some devices had been abandoned and a few deliberately disabled. Successful technology arrangements were often characterised by 'bricolage' (pragmatic customisation, combining new with legacy devices) by the participant or someone who knew and cared about them. With few exceptions, the current generation of so-called 'assisted living technologies' does not assist people to live with illness. To overcome this irony, technology providers need to move beyond the goal of representing technology users informationally (e.g. as biometric data) to providing flexible components from which individuals and their carers can 'think with things' to improve the situated, lived experience of multi-morbidity. A radical revision of assistive technology design policy may be needed. © 2013 Elsevier Ltd.