The Role of Information Infrastructures in Scaling up Video Consultations During COVID-19: Mixed Methods Case Study Into Opportunity, Disruption, and Exposure
Authors: Wherton Joseph , Greenhalgh Trisha , Hughes Gemma , Shaw Sara E 
Published: October 2022

Background
Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a “burning platform” for scaling up such services. As health care organizations look to expand and maintain the use of video in the “new normal,” it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward.

Objective
This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19.

Methods
A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants (eg, clinicians, managers, administrators, and IT support), ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al’s 3 perspectives on crisis and digital change: as opportunity (for accelerated innovation and removal of barriers to experimentation), disruption (to organizational practices, generating new dependencies and risks), and exposure (of vulnerabilities in both people and infrastructure).

Results
Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an “organizing vision” for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use.

Conclusions
For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed.