Emergency upscaling of video consultation during the COVID-19 pandemic: Contrasting user experience with data insights from the electronic health record in a large academic hospital

Background Video consultation (VC) has been scaled up at our academic centre attempting to facilitate and accommodate patient-provider interaction in times of social distancing during the recent and ongoing COVID-19 pandemic. Objectives This study evaluates qualitative outcomes with data insights from the electronic health record, to contrast satisfaction outcomes with the actual use of VC. Methods Healthcare providers and patients using VC during the COVID-19 pandemic at a large academic centre in the Netherlands were surveyed for user satisfaction and experiences with VC. In addition, quantitative technical assessment was performed using data related to VC from the EHR record. Results In total, 1,027/4,443 patients and 87/166 healthcare providers completed their online questionnaire. Users rated the use of VC during a pandemic with an average score of 8.3/10 and 7.6/10 respectively. Both groups believed the use of VC was a good solution to continue the provision of healthcare during this pandemic. The use of VC increased from 92 in March 2020 to 837 in April 2020. Conclusion This study strongly signals that VC is an important modality in futureproofing outpatient care during and beyond pandemic times. Further development in end-user technology is needed for EHR integrated VC solutions. Guidelines needs to be developed advising both patients and healthcare providers. Such guidelines should not solely focus on technical implementation and troubleshooting, but must also consider important aspects such as digital health literacy, patient and provider authentication, privacy and ethics.

AB STRACT B ackground: video consultation (VC) has been scaled up at our academic centre attempting to facilitate and accommodate patient-provider interaction in times of social distancing during the recent and ongoing COVID-19 pandemic.
Objectives: this study evaluates qualitative outcomes with data insights from the electronic health record, to contrast satisfaction outcomes with the actual use of VC .
Methods: healthcare providers and patients using VC during the COVID-19 pandemic at a large academic centre in the Netherlands were surveyed for user satisfaction and experiences with VC. In addition, quantitative technical assessment was performed using data related to VC from the EHR record.
Results: in total, 1,027/4,443 patients and 87/166 healthcare providers completed their online questionnaire. Users rated the use of VC during a pandemic with an average score of 8.3/10 and 7.6/10 respectively. Both groups believed the use of VC was a good solution to continue the provision of healthcare during this pandemic. The use of VC increased from 92 in March 2020 to 837 in April 2020.
C onclusion: this study strongly signals that VC is an important modality in futureproofing outpatient care during and beyond pandemic times. Further development in end-user technology is needed for EHR integrated VC solutions. Guidelines needs to be developed advising both patients and healthcare providers. Such guidelines should not solely focus on technical implementation and troubleshooting, but must also consider important aspects such as digital health literacy, patient and provider authentication, privacy and ethics.

INTRODUCTION
Since the outbreak of COVID-19 (coronavirus disease-19) caused by the coronavirus SARS CoV-2 late 2019, over 10 million detected cases of illness and over 500.000 confirmed deaths worldwide are reported. [1] On 11 March 2020, COVID-19 was declared a pandemic by the World Health Organization. [2] With no vaccine available yet, lockdown regimens, use of face masks in public areas and 'social distancing' have become-and still are-the most important strategies used for prevention. [3,4] Many countries have instigated rules enforcing person-to-person interactions to take place at a presumably safe distance. [4][5][6] In an attempt to prevent human-to-human transmission of the virus, whilst facilitating human interaction, lockdown restrictions are alleviated when this is deemed possible. [6][7][8] In this ongoing pandemic, strategies to prevent viral contamination to both prevent and cope with a possible second wave in healthcare are of great importance. [9][10][11][12] During this pandemic, hospitals face multiple challenges. First, they have to cope with the increasing demands on hospital capacity, resources, and staff resulting from great numbers of patients infected with SARS CoV-2. [13] Simultaneous, hospitals need to ensure proper care for non-COVID-19 patients in need of urgent medical attention. During the pandemic, taking care for COVID-19 patients needing Intensive Care Unit attention has become the primary focus of many institutions. Care for non-COVID-19 patients suffering from a variety of diseases and conditions including cancer is thus at risk of being compromised. [14,15] To avoid excessive backlogs impacting current and future healthcare, the challenge remains how to provide continuous high-quality healthcare in outpatient clinics during the pandemic, whilst limiting the chances of spreading the virus. [16] Replacing outpatient physical appointments with virtual care using video consultations (VC) provides a solution to this challenge. VC prevents the risk of spreading the virus, as vulnerable patients and their supporting relatives do not have to travel nor visit the hospital. [17] The use of a real-time video connection preserves important aspects of communication that cannot be accommodated over the telephone, such as visual interaction and non-verbal cues. [18] Indeed, several hospitals describe the value of using VC. [19][20][21][22][23] An important prerequisite for larger scale-up of VC is not only the availability of the solution to both provider and patient, but also to research the sustainability of this contact modality. [24] This in order to safeguard use and facilitate best implementation of VC in healthcare across settings as a fully accepted, normal contact modality.

J o u r n a l P r e -p r o o f
The aim of this mixed methods study is to evaluate satisfaction of VC among patients and providers whilst investigating the actual use, by a quantitative technical implementation study using data from the electronic health record (EHR).

Study design
This study uses a mixed-methods approach, combining a qualitative survey study with a quantitative observational implementation study in a large academic hospital. Mixed methods were used to generate a set of evidence in order to elucidate if high satisfaction rates will in fact lead to increased usage of VC. [25] Three departments (surgery, anaesthesiology and reproductive medicine) had VC opportunities prior to this pandemic. Patient-and healthcare provider satisfaction using VC in the outpatient setting was surveyed. Simultaneously, VC implementation was quantitatively assessed using data from the EHR, evaluating the number of VC's, duration of the consultations and technical aspects such as down-time of connection and number of successful-and failed connections.

Participants and setting
As per hospital policy, all non-urgent outpatient clinic visits were initially postponed. Starting up, healthcare providers from all departments were asked to select either telephone consultation (TC) or VC for patient interaction as alternative means for urgent outpatient clinic appointments that were initially scheduled as a physical contact. All patients and healthcare providers choosing to use VC as alternative means for physical contact were invited to complete our study questionnaire, evaluating their experiences with VC. The technical framework and VC-integration into the EHR is described elsewhere. [19] 1.3. D ata collection and analysis Prior to sending out the satisfaction questionnaire to patients and healthcare providers, a Privacy Impact Assessment (PIA) was performed by the hospital's Data Protection Officer (DPO). Patients were invited to complete the questionnaire via a message through their own patient portal of the EHR of the hospital, named MyChart TM (Epic Hyperspace 2017, Verona, USA), directly after their VC.
Healthcare providers were invited to complete a questionnaire after having performed at least five VC scheduled, to allow for a representative opinion towards their clinical value. Questionnaires were digitally distributed using LimeSurvey © survey software (LimeSurvey GmbH, Hamburg, Germany). Data was collected anonymously to ensure that patients' and providers' privacy was optimally protected, and was stored on the hospital's local server, following the European General Data Protection Regulation (GDPR). The patient questionnaire contained 11 statements with response options rated   Open text answers stated a telephone consultation was preferred over a VC by both patients and healthcare providers in case of a short follow-up call.

Patient and provider responses
Though healthcare providers' incentive was to use VC both during and after the pandemic, they  Table 3. Healthcare providers' responses to questionnaire items by using the Visual Analogue Scale (VAS). Items were measured on a scale from 0-100.

Thematic analysis of open questions answers by patients
Patients reported that VC can be a valuable supplement to care, but the value was dependent on the reason for consultation. Some patients feared that VC would be considered a replacement rather than a substitute to care. Related concerns included the inability to perform physical examination and the impact on the patient-healthcare provider relationship by the lack of physical contact.
Twenty-two patients mentioned the inability of elderly people to use a VC and the dependence on an appropriate internet connection. Patients express their concerns that the use of VC might be difficult for specific patient groups such as patients with low digital literacy, the elderly, patients with low socio-economic status and non-native speakers.
Although the use of VC is often considered as comforting because patients are in their own environment, when using VC for psycho-social purposes, such as psychiatric care, it should first be considered if the home environment can be considered a safe place for patients. An overview of topics and items are presented in Supplementary Table 1.

Thematic analysis of open question answers by healthcare providers
Especially considering the additional value of visual cues and the ability to use inspection and read emotions, healthcare providers are satisfied with the use of VC. They underline the benefits for the patients when receiving care from their own home in terms of patient related expenditure, inconveniences and logistics.
Considering the use of technology, the usability is considered high. The absence of wanted functionalities such as a virtual waiting room or a chat function leads to challenges in the workflow.
Thirteen healthcare providers preferred to use bigger screens than their smartphone. Residents specifically reported wanting the option for supervisors to dial-in to allow direct supervision during the

Number of attempts needed to establish a successful video connection
In order to start a VC, 1,052/1,546 (68%) patients needed a single attempt only to start the VC. For 336/1,546 (21.7%) patients, two attempts were needed to establish a successful video connection.
Out of all cases, 158/1,546 (10.2%) patients used three or more attempts to establish a connection.
Once a successful connection was established, no re-connections were necessary in 81.4% of the cases ( figure 3). If, after the start of a VC re-connection attempts were made, in most cases a PC or laptop was used which are not supported by the VC software of the hospital.

Overview used devices for VC
In 44% of cases, healthcare providers used their personal iPhone to use VC. Patients used an iPhone or an Android device in a similar amount of the VC. In 4% of VC, patients used a PC or laptop to start a video connection.

D ISCUSSION
This study evaluates the use of VC based on patient reported qualitative outcomes with data insights from the electronic health record. Patients and healthcare providers considered VC a promising solution to continue the provision of healthcare during the pandemic when physical consultations were restricted according to hospital policy. Consequently, there was a significant increase in the number of scheduled VC during this period. In comparison with other hospitals in the Netherlands, our usage of VC is considered high. [26] Although the average consultation duration was shorter than the scheduled consultation duration, both patients and healthcare providers felt they could discuss everything they needed to discuss during the consultation. Moreover, patients and healthcare providers were highly satisfied and would recommend a VC to other patients and colleagues respectively. Both patients and healthcare providers alike stated they would prefer the continued use J o u r n a l P r e -p r o o f and further implementation of VC, also after this pandemic. However, when restrictions for patients visiting the outpatient clinics were alleviated, the increase of scheduled VC stagnated.
There are a few reasons that may explain for this stagnation. First, the period of strict regulations might have been insufficient to convince late adopters (healthcare providers who need to be convinced of the advantage of VC by peers or the actual laggards). Studies show, that first-hand experience is vital to experience the benefits of VC. [27] Especially to convince hesitant healthcare providers that the use of VC offers more benefits than the convenience of a telephone consultation. In scaling up VC as a regular contact modality, It may help to stress to the provider that VC is associated with a higher patient satisfaction and -understanding when compared to telephone consultation due to the presence of visual cues and non-verbal communication. [   VC is associated with higher patient satisfaction and patient understanding when compared to telephone consultation due to the presence of visual cues and non-verbal communication.

WHAT THIS STUDY ADDS
 This study shows that the replacement of outpatient care appointments by VC is feasible, without a detriment to the quality of care provided even with shorter consultation durations.
 Even within optimal conditions, the adoption of VC by healthcare providers is highly dependent on personal beliefs towards digital solutions. To overcome unnecessary variation due the willingness -or unwillingness -to use VC by a single healthcare provider or group of providers, the use of VC should be integrated in standardized guidelines.