Clinician Perspectives on Implementing Video Visits in Home-Based Palliative Care

Background: Despite the increasing use and acceptance of technology in health care, there is limited evidence on the usefulness and appropriate use of telehealth in home-based palliative care (HBPC). As part of the process evaluation of a pragmatic trial of video visits in HBPC, we assessed clinician experience with video visit implementation. Methods: We assessed clinicians' experiences with and perception of the usefulness and appropriateness of video visits using anonymous surveys and brief qualitative interviews with a subset of survey participants. Qualitative analyses were guided by sociotechnical frameworks that emphasize technology's “value proposition” for its end users as being key to adoption. Results: Clinicians (36 physicians and 48 registered nurses) generally had favorable attitudes toward video visits and telehealth. Respondents felt confident in the skills needed to make their role in video visits successful. Clinicians were neutral on whether video visits were useful for their practice or enhanced the patient–caregiver experience. Clinicians found video visits to be most appropriate for follow-up care (as opposed to start of care). The interviews yielded two themes that complemented the survey findings: (1) factors enhancing the value proposition (positive responses from patients and families and convenience) and (2) factors diminishing the value proposition (issues related to the technology and scheduling). Discussion: Our findings provide insights into clinicians' experiences with implementing remote video physician consultations, facilitated by a nurse in the patient's home in the pre-COVID-19 era. Clinician views about video visits may have shifted with the pandemic, which occurred after our data collection was complete. Clinical Trials Registration No. NCT#03694431.


Introduction
Advances in technology such as the use of telehealth or video consultation (video visits) have made it feasible for clinicians to provide clinical care and support in the home setting. 1 Video visits allow patients to have face-to-face interaction with providers, enable provid-ers to observe patients and conduct visits, while at the same time lessening travel burden. [1][2][3][4][5][6][7] Several studies indicate that clinician acceptance, driven by its relative value, is the most important factor in the uptake and utilization of video visits. [5][6][7][8][9] Despite the increasing use and acceptance 7 of video visits between clinic-based physicians with patients in their homes, 10 there is limited information on how physicians and nurses experience the use of facilitated video visits with patients and family caregivers in home-based palliative care (HBPC).
This report is a substudy of a larger comparative effectiveness trial (HomePal) that compared a standard HBPC model with a tech-supported model that included use of nurse to physician video consultation. 11 Standard HBPC typically included separate home visits by physicians and nurses. The tech-supported model relied on the nurse who was in the patient's home to facilitate a synchronous video consultation between the patient and family with the remote physician; this approach to video visit use was intended to minimize disparities in access to technology by patients and families. We expected that early video access to the physician for discussion and concurrence on the treatment plan would build trust and confidence with the patient/caregivers, potentially reducing the need for an in-home physician visit. Physicians had the discretion of conducting home visits as needed in the techsupported model. Half of the teams were randomized to implement the standard HBPC model and the other half, the tech-supported model.
The aim of this analysis was to assess the usefulness and appropriateness (i.e., value proposition) of video visits from the perspective of HBPC physicians and nurses, anchored within the NASSS framework 12,13 (nonadoption and abandonment of technologies by individuals and the challenges to scale-up, spread, and sustainability of such technologies in health and care organizations).

Methods
We conducted a cross-sectional anonymous survey of HBPC clinicians across 14 study sites to assess the usefulness and appropriateness of video visits and attitudes toward telehealth. The survey was administered approximately eight months after the trial started enrolling participants. The survey was approved by our institutional review board as part of the main study. 11 All HBPC clinicians (physicians, n = 83; full-and part-time registered nurse case managers, n = 105) were invited to participate in the survey through e-mail and participation was strictly voluntary. Respondents completed web (REDCap) or paper surveys.
A 26-item physician and a 20-item nurse surveys were developed based on a review of the literature [14][15][16][17][18][19] and underlying conceptual framework of relevant study-specific domains: quality of physician-patient communication, perceived use and usefulness, satisfaction with the current program, perceptions of telehealth, and perceived effects on patients and caregivers. All questions used a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) with the exception of one question on perceived effects of video visits on patients-family caregivers (À5 = very negatively to 0 = neutral to 5 = very positively).
To supplement the survey data and further assess clinician perspectives and overall experience on the use of video visits, clinicians were invited to participate in 10-15 minutes semistructured interviews over the phone or in-person upon completing the survey. Three qualitative interviewers (T.O., M.M., and H.N.) used a semistructured guide to probe the clinicians' experiences with video visit implementation, barriers and facilitators, and changes and recommendations. A notetaking template was used to systematically record the interview data.

Analysis
We computed descriptive statistics to summarize survey results. Interview notes were imported to NVivo for coding and analysis by T.O. and M.M. and were reviewed with C.M. to further validate the thematic coding. 20 In this article, we report on the analysis of one theme, which was heavily represented in the data: the value proposition of video visits to clinicians.

Survey
A total of 84 clinicians responded to the survey, which included 36 physicians (45%) and 48 (49%) nurse case managers. At least one physician and one nurse from each of the 14 sites participated in the survey. All physician respondents reported having conducted video visits and half of the nurses reported that they conducted video visits as expected per the HomePal study design ( Table 1).
Use of video visits. Video visits were used primarily for follow-up visits as opposed to admission/startof-care. Of the 36 physicians who reported having conducted a video visit, 16 (44%) reporting having conducted video visits for admission/start-of-care, whereas 28 (76%) reported conducing video visits at follow-up. Findings among nurses were similar. We also asked physicians which types of visits were most appropriate for video; the results were consistent with physicians indicating a preference for use of video for follow-up care. Attitudes toward video visits and telehealth. Based on responses rated on a 5-point scale (1 = strongly disagree to 5 = agree), clinicians had generally positive attitudes toward video visits and telehealth. They reported that video visits were a useful addition to HBPC services, that telehealth will be a standard way of health care delivery in the future, and overall satisfaction with the video visits. Physicians and nurses generally disagreed that technology hinders the care experience. Attitudes were more neutral with regard to preference for inperson care among both physicians Perceived impact on patients and families. We asked clinicians to rate the extent to which they believe video visits has had a negative (À5 to À1), neutral (0), or positive (+1 to +5) effect on patients and families. Both Attitudes toward video visits and telehealth (1 = strongly disagree to 5 = strongly agree) Overall, I find that using the technology hinders the care experience 2.4 (1.  Debrief interview. Seven physicians and seven nurses provided additional feedback on their experience with video visits. Two overarching themes emerged from these interviews ( Table 2): Factors enhancing the value proposition for video visits. Clinicians shared that patients and families responded positively to video visits. They also noted that video visits offer convenience, especially for physicians.
Factors diminishing the value proposition video visits. Clinicians noted that issues related to the technology (e.g., connectivity and quality) and scheduling were substantial barriers to conducting video visits. Video visits placed additional burden on the nurses who facilitated the encounters.

Discussion
The survey and interviews provided complementary findings and insights into clinicians' experiences with implementing video visits as part of the HomePal trial. Clinicians experienced both benefits and challenges of delivering care through the video platform. Survey results showed that video visits were primarily used for follow-up visits and that physicians felt competent When I did my first follow-up visit with a stable patient, it was great. I saved a car trip and was able to assess the patient's status. (MD) Clinically, the VV has helped to assess how the patient looks, their disease progression to plan for any transitions. In the past, the reports might be delayed for up to two weeks since we depend on the report out from IDG. VV help accelerate communications around emergent issues. I feel less stressed and anxious about being in the dark regarding the patients' status and family is also more aware of the greater involvement by the MDs (RN) Factors diminishing the value proposition for HBPC clinicians When technology is hard to use (due to connectivity and quality issues), it greatly diminishes the value of video visits.
Physicians and nurses noted that video visits place additional burden on nurses, who set up and facilitate video visits during their home visits. Scheduling is an ever-present challenge.
Clinicians reported that some clinical issues, such as visualizing skin problems, were not easy to manage by video. Our study has limitations that are important to consider when interpreting the results. The data are crosssectional, and as such the findings represent a snapshot of clinicians' views of and experiences with video visits. The survey and interviews included a convenience, volunteer sample of clinicians participating in the trial. Although clinicians represented a range of perspectives from different study sites, respondents may not be representative of all HBPC clinicians. Finally, this study was focused on only one of many use cases for video visits and was conducted before the COVID-19 pandemic.
Findings from this report further reinforce the lessons learned from the HomePal trial that are reported elsewhere. 21 Given the unprecedented adoption of virtual care in response to the pandemic, efforts should focus on ensuring more reliable connectivity so clinicians can focus on providing care, not technical troubleshooting. In addition, optimizing physician and nurse schedules through different arrangements, including assigning a pool of dedicated physicians to provide video consultations on demand, may address the flexibility nurses need in the home care setting. Addressing these two issues are critical for streamlining the video consultations for physicians, nurses, patients, and families.