Table 1
Description of the interventions and their implementation process.
| OFFLINE VIRTUAL CONSULTATION BETWEEN LEVELS | ||
|---|---|---|
| 1ST CYCLE | 2ND CYCLE | |
| Content | Asynchronous virtual consultations in chronic diseases care via digital platform and protocol repository between primary care and secondary care physicians | Maternal and perinatal health is incorporated as a an area for consultation |
| Trained physicians | 68 primary care physicians | 2 secondary care physicians |
| 13 secondary care physicians | ||
| Number of consultations conducted | 6 consultations; accessed 43 times to look up information | 5 consultations; accessed 165 times to look up information |
| Duration | 6 months (October 2016 – April 2017) | 8 months (May – December 2017) |
| JOINT TRAINING MEETINGS | ||
| Content | Joint training meetings, based on clinical cases, on maternal and perinatal care and chronic diseases | |
| Number of sessions caried out | 4 maternal and perinatal health | |
| 1 chronic diseases | ||
| Maternal and perinatal health: 52 primary care 12 Gynecologists, 1 Clinical nutritionist | ||
| Participants | Chronic diseases | |
| 20 primary care | ||
| 2 Internists | ||
| 1 Clinical psychologist, 1 Pneumologist, 1 Ophthalmologist, 1 Emergency physician, 1 Integralist physician | ||
| Duration of implementation | 8 months (May – December 2017) | |
Table 2
Final composition of the sample of informants.
| STATE MANAGERS | MIDDLE-RANKING OFFICIALS | SECONDARY CARE PHYSICIANS | PRIMARY CARE PHYSICIANS | ||
|---|---|---|---|---|---|
| Individual Interview| | Local Steering Committee | 2 (Male)/ 1 (Female) | – | – | – |
| Professional Platform | – | – | – | 1 (Male) | |
| Discussion Group 1 | Local Steering Committee | – | 2 (Male)/1 (Female) | – | – |
| Discussion Group 2 | Local Steering Committee | – | 1 (Male)/1 (Female) | – | – |
| Professional Platform | – | – | 3 (Male) | 2 (Female) | |
| Discussion Group 3* | Local Steering Committee | 1 (Male) | 3 (Male) | – | – |
| Professional Platform | – | – | – | 1 (Male)/1 (Female) |
[i] * Discussion Group conducted in 2 sessions.
Figure 1
Offline virtual consultations: results perceived on care coordination and related factors.
Table 3
Examples of textual quotations regarding opinions on the results of the offline virtual consultations and factors influencing their implementation.
| Results on improved coordination of clinical management | |
| a- Interconsultation improves clinical management of patients | “The interconsultation helped me exchange management concepts with the specialist, and. obviously, his responses about the patient to keep him under control and happy.” (Professional Platform/Primary Care) |
| Factors that influenced on offline virtual consultations implementation Contextual | |
| b- The system improves access to Official Mexican Standards Clinical Practice Guideline | “If I had any doubts, then I checked the Official Mexican Standards Clinical Practice Guideline to get answers … then I practically accessed to get information … [which was] very useful for me” (Professional Platform/Primary Care). “Moreover, in the system we could also make enquiries about pregnancy, childbirth and puerperium, since the official standards were there, no many problems. Regarding chrome diseases, we began to focus on manuals and the Clinical Practice Guideline.” (Professional Platform/Primary Care) |
| Related to the healthcare network Structural | |
| c- System access is limited due to a lack of infrastructure | “First, we didn’t have internet in fact we just got internet a few months ago, and because there was none… at the health centre you couldn’t ask questions. If I consulted information from the system I had to connect fron home” (Professional Platform/Primary Care). “The internet system implied connectivity in the units, which they have, but that connectivity is not very efficient, computers are necessary, not all of the units had computers… and many units with computers did not have connectivity. That connectivity was even paid by physicians.” (Local Steering Committee/Manager) |
| Organisational | |
| d- Providing technological infrastructure is influenced bymanager’s limited support or interest | “When we spoke with the authorities, some situations that could hinder the system (the offline virtual consultations) were perceived. One of them was the lack of computers and internet at the Health Centres, for which a census was carried out… and after the census, the Ministry of Health committed to correct this situation… when a government institution is committed, there is 20% of certainty they will comply, while 80% they won’t comply. That happened here or at least primary care physicians still complain about this and they still report that they do not have a convenient internet access and they sometimes do not even have computers.” (Local Steering Committee/Manager). “After all the paperwork one has to fill out (in primary care), in the end you are going to forget about the system (offline virtual consultationes), it was not intentional. However, somehow SESVER got involved and focused much more on obstetrics, so the training in obstetrics was very good. If SESVER would engage with the system (offline virtual consusltations) or with chronic patients, or with comprehensive care… not only with obstretics, I think it would really be much easier for us… I still feel that the main cause is that SESVER did noy join this, as is not part of their work plans.” (Professional Platform/Primary Care). |
| Related to professionals | |
| e- Fear of criticism diminishes interconsultations | “I think the problem (that the system would not work) is they are afraid of being criticised, they will criticise us… criticism is not going to favour absolutely anything, the idea was to unite in order to establish a more open and cordial dialogue, avoiding precisely that feeling that we are annoying.” (Professional Platform/Secondary Care) |
| Related to participatory action research process and intervention content | |
| f- Directionality when selecting causes for the system to be rarely- used, as problems identified are not adequately responded | “The research team had already visualised that they wanted to implement this system…surely they had already planned to do so…this is an important issue”. (Professional Platform/Primary Care) “It seemed to me that this search (for interventions to be implemented) by some members of the university team was biased…with the causes that were identified in those studies, then the action plan began to be designed …we were taking risks to start designing solution strategies that might not solve the problem and at the end of the period we were going to realise it did not work, but hey, it is part of the investigation, if something is set in motion and does not work, well, at least it is proven.” (Professional Platform/Primary Care) |
| g- Too many items in the interconsultation form diminishes interest of participants | “At first I was involved, I tried to type info of patients, do the summaries and all that, but the truth is that I could devote that time to make my notes, organise my files, I did it for a while, when I realised that it really took away a lot of my time.” (Professional Platform/Primary Care) “The items were practical for me (interconsultation format), those considered as necessary to make consultations during the meeting held by primary, secondary and tertiary physicians were included.” (Local Steering Committee/Manager) |
Figure 2
Joint training meetings: results perceived on care coordination and influencing factors.
Table 4
Examples of verbatin regarding opinions on results on coordination of joint training meetings and factors that influenced their implementation.
| Results on improved coordination of clinical management | |
| a- Treatment, adequacy and relevance of referrals were improved | “Something very important is that (in a referral) the woman was there with both the proper documentation and the clamp-crush technique well done Then they had already learned this in the seminar, so, how have you noticed this? Changes may be very subtle, but can be noticed” (Local Steering Committee/Manager). “There was an impact on matters regarding delicate patients, who have arrived at the hospitals in better conditions and they were previously treated, that means that there was a positive result in terms of contact between the secondary, tertiary and primary levels of care.” (Local Steering Committee/Secondary Care) |
| Results on improved factors related to coordination | |
| b- Use of direct communication | “Today everyone has a phone with WhatsApp… they take a photo and send me the referral and I’ll send you the reply letter back and I’ll tell you this, send that send, give me that very quickly.’’ (Local Steering Committee/Manager) |
| Factors that influenced on holding joint training meetings Contextual related to policies and political cycle | |
| c- Alignment with policies favoured institutional support when considered as an opportunity | “When it turns to maternal death, the first seminar was in large part due to the support received by the Directorate of Medical Care – we have to abate this problem that is screwing us up, and, suddenly, the problem became bigger, and, well, we have to see how to resolve.” (Local Steering Committee/Manager) |
| Related to participatory action research process and intervention content | |
| d- Attitude of facilitators, clinical case resolutions and practical activities enhanced involvement and fostered a climate of equality | “Even during the same seminar, some of the secondary care physicians were really conflicted with the relationship between primary and secondary care, but in the last seminars no longer. Even I think that the word spread about – those who attend (specialists.) They are not going to ask questions or be rude – but in the last seminar one or two took out their frustrations… but most of them attended with an open perspective to leans and improve, that’s what interaction is about” (Local Steering Committee/Secondary Care). “Training dynamics shown by secondary care physicians was important, as they were perceived as equals’ And that was the difference from other trainings.” (Local Steering Committee/Manager) |
| e- Topics (maternal health) and curricular value encouraged involvement | “Everything related to maternal and child health is much more frequent, it is a priority, I am not saying that chronic degenerative diseases are not important in fact, they are one of the main causes of morbidity and mortality… the staff have a certain affinity with health problems, it seems that when chronic degenerative diseases see the problem with the user is not going to be solved immediately, our mentality seems to change” (Professional Platform/Primary Care). “It was fortunate that maternal health is now considered, because it is a daily walk, perhaps we don’t receive many chronic degenerative patients, but pregnant women do, every day.” (Professional Platform/Primary Care) “(The incentive) for the primary care physicians was to give them their duly registered certifications, so that they can use them for job promotion and so on.” (Local Steering Committee/Manager) |
| Related to the healthcare network (organisational and individuals) | |
| f- Freeing up and protecting time of participants facilitated design and implementation | “In order for me to get fully involved, I only had to say I was approved (by the Directorate of Medical Care), so I can enjoy a certain autonomy of the staff under my command, use the resources I was allocated for activities for both (the joint naming meetings) and the strategic plan” (Local Steering Committee/Manager). “It was our turn to establish the leadership in terms of training, managing with the health jurisdiction the call for the groups of participants, discuss with the directors and managers of the regional hospitals the participation of the teams of facilitators and see how to move forward (because of resistance).” (Local Steering Committee/Manager) |
| g- Resistance from some primary and secondary care beads delayed involvement of physicians | “There was a certain resistance (from management positions), obviously, to allow the primary care physicians to be out for three days, and for the secondary care… no way you are going to take away my specialist that gets the job done, because he has to deliver a gaining course.” (Local Steering Committee/Manager) |
| h- Less support resulted in cancelling seminars on chronic diseases | “That political support for other programs, which perhaps does not occur for COPD or chronic degenerative diseases, because they always have programs for diabetes, but they aren’t a priority… (The second replication of the course on chronic diseases) was cancelled in December.” (Professional Platform/Secondary Care) |
| i- Less seniority encourages interest to get involved | “In the last courses we saw more involvement, more acceptance by physicians, which has a lot to do with staff s seniority, staff that is very old have many tricks and, indeed, are very resistant to methodology.” (Local Steering Committee/Manager) |