Prioritising enhancements across allied health telehealth services in a metropolitan hospital: Using a concept mapping approach

Abstract

Introduction

A prior study examining perceptions of Allied Health Professions (AHP) telehealth services at a metropolitan hospital highlighted multiple issues impacting service uptake, operationalisation, and delivery. Concept mapping methodology was utilised to address these issues and prioritise actionable telehealth service improvements.

Methods

Representatives (n = 22) from seven AHP departments and consumers generated statements addressing the question: ‘What do we need to do to enhance and sustain telehealth services?’ Statements were synthesised and then clinicians and managers sorted them into similar groups and assigned each statement a ranking of perceived (a) importance and (b) changeability. Multivariate and multidimensional scaling was undertaken to develop a final prioritised set of goals for change.

Results

Ninety-six unique statements were generated as actionable goals for change. Statements were grouped into 13 clusters relating to improvements in staff support, infrastructure, consumer support and organisational processes. All clusters were rated >50% for importance (range 3.3–2.4 out of 4) and changeability (range 2.6–2.1 out of 4). Twenty-six statements were ranked highest for importance and changeability. Key prioritised areas were staff training, consumer advocacy and engagement, telehealth operations and workflow.

Conclusion

Concept mapping was an effective process for generating a prioritised list of actions to enhance AHP telehealth services.

Keywords

Allied health telehealth concept mapping consumer engagement sustainability

Introduction

During COVID-19, health services rapidly implemented telehealth models to provide care during social distancing restrictions. While adapting to these new models was challenging,^1–5 it demonstrated the benefits of telehealth for consumers and health services on a scale. With the return to usual care, organisations need to capitalise on the expertise gained from implementing these models and embed telehealth into mainstream clinical practice.^1,2,6

This research team recently explored consumer, clinician, and administration staff perspectives of an allied health professions (AHPs) telehealth service (specifically videoconferencing) during COVID-19.¹ Results confirmed telehealth was viewed positively, however, improvements were needed for long-term sustainability. While organisational support was confirmed, it was acknowledged that re-designing telehealth services across a diverse range of disciplines would require multiple stakeholder consultations, and commitment from healthcare staff to advocate for, and adopt service change.

Hence the aim of this study was to engage key stakeholders to identify and prioritise actionable goals that would enhance and sustain AHP telehealth services.

Methods and results

Setting and participants

This study was conducted within the AHPs service line of a quaternary facility in Brisbane, Australia. Seven AHP departments participated: audiology, nutrition & dietetics, occupational therapy, physiotherapy, psychology, social work, and speech pathology. Participants included managers (n = 9), clinicians (n = 7), administration officers (n = 4) and consumer representatives (n = 4). All participants provided informed consent. A waiver from ethical review was provided by the Institutional Human Research Ethics Committee (LNR/2020/QRBW/64414).

Concept mapping process

Concept mapping is a mixed methods research approach that can be used to guide initial change management processes. It has been used successfully to integrate clinician and consumer preferences for health care^7–9 and inform service improvement.^10–12 Guided by Foley et al.,¹⁰ the first five stages of the concept mapping process (Figure 1) were undertaken for this study: (1) preparation, (2) statement generation, (3) structuring, (4) representation, and (5) interpretation. As each stage influences the next, the methods and results pertaining to each phase are presented together below. The final stage, Stage 6 – utilisation, which involves planning the application of the results, will be undertaken in a future study.

Figure 1.

Stages 1 to 5 of the concept mapping process.

Stage 1 – preparation

Firstly, all participants attended a group meeting, where the results of a recent study exploring consumer, clinician, and administration staff feedback on the AHP telehealth service were provided.¹ Concept mapping methodology was also explained.

Stage 2 – statement generation

Then, small focus groups were conducted with each department and the consumer group, facilitated by a member of the research team. Participants considered telehealth service feedback (Stage 1) and brainstormed solutions to the question: ‘What do we need to do to enhance and sustain telehealth services?’ Discrete statements were generated for each idea/solution. Following each focus group, the statements were sent to participants for member checking and to add additional statements as necessary. The research team then compiled all statements and removed duplicates. On completion of Stage 2, a list of 96 unique statements was generated as potential areas for telehealth service enhancement.

Stage 3 – structuring

Structuring involved two steps undertaken individually by each participant. Firstly, participants sorted statements (provided on individual cards) into groups based on similarity. They could create as many groups as needed but could only put each statement into one grouping, which they then named by theme. The cards were shuffled between participants to avoid a priming effect. Next, participants were provided with the list of statements in an excel spreadsheet and asked to rank each statement according to (1) how important it was (0 = not important to 4 = extremely important) and (2) how easy it was to change (0 = not at all changeable to 4 = extremely changeable).

Figure 2.

Dendrogram illustrating 13 cluster themes.

Stage 4 – representation and Stage 5 – interpretation

Stage 3 data was analysed using free open-source software R-CMap.¹³ Firstly, multidimensional scaling was used to generate a stress value, which relates to a ‘goodness of fit’ between the raw and processed data to examine the statistical strength of the results. The stress value (0.327) was within the accepted range for concept mapping,^14,15 indicating full analysis could proceed.

Hierarchical cluster analysis examined how the general themes underlying the statements were grouped by participants, depicted on a dendrogram. A dendrogram using a 13-cluster arrangement (Figure 2) was generated and the clusters were named by four members of the research team after reviewing the statements within each cluster. These covered a wide range of themes including governance, strategic planning and evaluation, infrastructure and interoperability, workflow processes, consumer awareness and staff training. The cluster names, theme descriptions, example statements, and mean importance/changeability ratings are presented in Table 1.

Table 1.

Characteristics of cluster themes.

Cluster ID	Cluster theme	Theme description	Example statement	Number of statements	Mean importance rating	Mean changeability rating
1	Dedicated telehealth support	Describes staffing strategies to enable specific and dedicated telehealth support to both consumers and staff.	Establish a dedicated telehealth AO position within each department/hub.	8	2.73	2.14
2	Operational support	Describes operational processes that would support staff engagement and consistent learning practices.	Nominate clinical ‘telehealth champion/s’ within each department/clinical team who have undertaken advanced telehealth training.	6	2.93	2.51
3	Infrastructure and interoperability	Describes the physical and technological requirements of the organisation in order to facilitate telehealth consults.	All clinical spaces have the technology available to complete a telehealth consult.	14	3.11	2.19
4	Consumer feedback	Includes mechanisms to facilitate consumer feedback regarding their telehealth experience.	Consumers are engaged to provide feedback to educate clinicians on the benefits of accessing care via telehealth.	3	2.95	2.63
5	Consumer awareness	Describes strategies to facilitate consumer awareness around the availability and appropriateness of telehealth for their referred health condition.	All consumers will receive information on telehealth that is specific to the clinical service at the time of referral acceptance.	8	2.86	2.61
6	Staff training	Includes various mechanisms of how training can be designed and delivered to support staff knowledge, expectations and skills regarding telehealth.	Structured telehealth training is to be provided to all staff (HP/AO) as part of their induction.	16	2.8	2.51
7	Knowledge generation and dissemination	Provides opportunities to increase clinician knowledge of telehealth and evidence within relevant clinical settings.	Provide opportunities to disseminate evidence towards telehealth to clinicians.	4	2.8	2.59
8	Resources tailored to consumers’ needs	Describes the need to be flexible and responsive to the way in which information is packaged and accessed by consumers.	Technical support should be available to consumers through different modes of communication (e.g. text, phone, and email).	6	2.76	2.05
9	Clinical models and guidelines	Examines ways in which telehealth appointments can be consistently offered, and conducted, to relevant clinical cohorts.	Develop clinical pathways within relevant clinical areas to provide a clinical consensus on when telehealth is to be offered/provided in a consumer’s episode of care.	7	2.71	2.32
10	Workflow processes	Reinforces the need for established workflow processes that are clear, consistent and efficient.	Workflow processes are established to support rapid change in appointment mode (e.g. consumers unable to attend an in-person appointment are converted to telehealth).	4	3.3	2.61
11	Consumer advocacy and support	Describes strategies to support patients in their ability to choose and participate in telehealth appointments.	Staff (AO/HP) are to engage with carers/support persons to support consumers to have confidence and the ability to access care via telehealth.	9	2.96	2.44
12	Strategic planning and evaluation	Examines ways in which telehealth activity ‘targets’ can be set and monitored.	Provide regular audits and feedback to the department/team on telehealth activity.	5	2.44	2.42
13	Governance	Describes ways in which telehealth can be embedded within normal clinical care processes.	Senior clinical staff are involved in an overarching consensus process to determine types of interventions/clinical cohorts that are clinically appropriate for telehealth, which is subsequently applied in the triage process.	6	2.81	2.63

AO: administration officer; HP: health practitioner.

A cluster rating map examined the relationship between the statements within each cluster (Figure 3). This displays: (1) how closely related statements are to each other, as depicted by their proximity on the map (i.e. closer the proximity = closer the relationship); (2) level of participant agreement between statement themes within each cluster, illustrated by cluster size (i.e. high agreement = smaller cluster size); and (3) the uniqueness of each cluster theme illustrated by the distance between each cluster (i.e. greater distance between clusters = clusters are more unique). All clusters were comparable in their uniqueness of theme except for clusters 3 (infrastructure and interoperability) and 8 (resources tailed to consumers’ needs) which overlapped for Statement 32 ‘Utilise a generic phone support service that provides support for patients to set up telehealth’.

Figure 3.

Cluster rating maps with numbered statements listed within each cluster.

The pattern matching graph (Figure 4) displays the mean rating of importance and changeability for all statements within each cluster. Cluster 10 ‘Workflow processes’ was rated highest for importance whilst Clusters 4 ‘Consumer feedback’ and 13 ‘Governance’ had the equal highest rating for changeability. For 12 of the clusters, the gradient between importance and changeability was negative, indicating that whilst participants viewed the themes as being important, they also felt that enacting change might be difficult. One cluster ‘Strategic planning and evaluation’ had a neutral gradient with a mean score of 2.4 for both importance and changeability. Although clusters were ranked as having higher importance than changeability, overall, all the clusters were rated >50% for both importance (range 3.3–2.4 out of 4) and changeability (range 2.6–2.1 out of 4).

Figure 4.

Pattern matching comparing the importance and changeability of 13 clusters.

Finally, the Go Zone (Figure 5) is a scatterplot where each statement is placed into one of four quadrants according to its overall importance and changeability. The ‘green zone’ contains statements ranked highest in mean importance and changeability and should therefore be prioritised in goal setting to achieve both meaningful and efficient change. There were 26 (27%) statements in the green zone (Table 2) representing 11 of the 13 clusters. Cluster 6 ‘Staff training’ had the most statements falling within the green zone. In the opposite quadrant, the ‘red zone’ shows statements with the least importance and lowest changeability. There were 30 statements (31%) in the red zone predominantly coming from Cluster 1 ‘Dedicated telehealth staff’ and Cluster 3 ‘Infrastructure and interoperability’. As this study focused on identifying actionable areas for improvement, the red zone results are not discussed in detail.

Figure 5.

Go zone graph illustrating the importance and changeability rating for each statement.

Table 2.

Individual statements are identified within the ‘Go Zone’.

Cluster ID	Cluster theme	Statement ID	Statement
2	Operational support	45	Establish and maintain an AO manual of procedures for all non-clinical processes associated with telehealth.
2	Operational support	46	Nominate an AO telehealth ‘champion’ across the AHP service line to support all AOs to ensure consistency and ongoing training.
3	Infrastructure and interoperability	5	All clinical spaces have the technology available to complete a telehealth consult.
3	Infrastructure and interoperability	69	The technology required for telehealth needs to be accessible, familiar and convenient to the consumer.
4	Consumer feedback	6	Consumers are provided with an opportunity to provide feedback on telehealth consult at the completion of the consult.
4	Consumer feedback	14	Consumers are engaged to provide feedback to educate clinicians on the benefits of accessing care via telehealth.
5	Consumer awareness	7	All consumers will receive information on telehealth that is specific to the clinical service at the time of referral acceptance.
5	Consumer awareness	11	When organising a telehealth appointment, the clinician is to provide the consumer with a clear explanation of what telehealth is and specific reasons why the delivery mode has been suggested.
5	Consumer awareness	27	Every consumer should be provided verbal communication about what telehealth is and what the benefits are.
6	Staff training	12	Education provided to all relevant staff regarding current funding arrangements for telehealth/telephone/in-person appointments.
6	Staff training	58	Staff (AO/HP) are provided with designated offline time to complete telehealth training.
6	Staff training	60	Step-by-step instructions for clinicians should be developed on how to use all available platforms on all available/compatible devices.
6	Staff training	79	Telehealth training must occur when clinician moves into appropriate clinical rosters.
6	Staff training	84	Provide training that is specific to the discipline/clinical service to support the adaption of clinical skills to be provided via telehealth.
6	Staff training	96	Written guidelines regarding checklists/prompts are to be provided to all new staff.
7	Knowledge generation and dissemination	40	Ensure staff awareness regarding the telehealth platforms currently endorsed by the organisation.
8	Resources tailored to consumer needs	47	Consumer telehealth resources are available in different formats (e.g. paper handout, link to website, and video).
8	Resources tailored to consumer needs	48	Ensure patient telehealth resources are adapted to support CALD populations.
8	Resources tailored to consumer needs	66	Technical support should be available to patients through different modes of communication (e.g. text, phone, and email)
9	Clinical models and guidelines	19	Develop clinical pathways within relevant clinical areas to provide a clinical consensus on when telehealth is to be offered/provided in a consumer’s episode of care.
9	Clinical models and guidelines	22	Develop and implement specific guidelines regarding the assessment and response/management of specific safety scenarios within telehealth consult (e.g. acute suicide risk, domestic violence risk, and child safety).
10	Workflow processes	23	Each AHP hub/team establishes a coordinated workflow process for the organisation/scheduling of telehealth services.
10	Workflow processes	55	Workflow processes are established to support rapid change in appointment mode (e.g. consumers unable to attend an in-person appointment are converted to telehealth).
10	Workflow processes	62	Streamlined processes are established to access interpreter services via telehealth to optimise clinical interaction.
11	Consumer advocacy and support	61	Step-by-step instructions for consumers should be developed on how to use the telehealth technology for all platforms on all available/compatible devices.
12	Strategic planning and evaluation	39	Increase telehealth activity of the medical staff in MDT clinics where there is a strong AHP involvement to encourage MDT telehealth sessions.

AO: administration officer; AHP: Allied Health Profession; CALD: culturally and linguistically diverse; MDT: multidisciplinary team.

Discussion

This study utilised a concept mapping approach to identify and prioritise telehealth service improvements across an AHP service line. Consultation with managers, clinicians, administration officers and consumers highlighted enhancements across several key areas. Statements relating to staff training, consumer engagement, and telehealth operations/workflow rated highest in the prioritised list of actionable goals. These findings have provided the initial direction for service improvement to establish a sustainable telehealth model that delivers effective and efficient care while meeting end-users needs.¹⁶

A well-trained and confident workforce is essential for effective service delivery.^17–19 The group acknowledged this with ‘Staff Training’ contributing the highest number of statements in the ‘green zone’. Improved training across technical and clinical/operational aspects of service delivery was suggested including staff having dedicated time to learn (1) evidence-based telehealth models, (2) how to adapt in-person skills to telehealth delivery and (3) how to address safety issues and/or risks during remote consultations. These recommendations are consistent with published telehealth guidelines^17,19,20 as is maintaining staff skills through task re-orientation when changing workloads and having access to quick reference guides and technical support. Improving staff knowledge of funding arrangements for telehealth appointments compared to other models (e.g. telephone) was also suggested as a service sustainability strategy.

The rapid adoption of telehealth during COVID-19 challenged consumer readiness and impacted engagement.^1,2,19,21 The group identified this as an area for enhancement by prioritising >30% of statements in the Go Zone on this topic. Acknowledging that the offer of telehealth appointments is commonly clinician directed,¹ the group suggested strategies to empower consumers to become more actively involved in choosing how they access their healthcare appointments. This included education on (1) the benefits/limitations of telehealth, (2) which AHP services could be accessed via telehealth and (3) providing avenues for feedback on telehealth sessions. Actively discussing telehealth models during clinic appointments and/or providing written information (e.g. brochures) were considered appropriate forms of consumer education. Ensuring equity of access for clients was also highlighted through the recommendation of designing relevant and culturally appropriate resources, in a range of formats (e.g. verbal and written/online), to increase engagement for all consumer groups (e.g. First Nations peoples).

Telehealth operations/workflow was the third prioritised area of service enhancement, evidenced by ‘Workflow processes’ receiving the highest rating for importance. A critical element of effective and efficient telehealth services is the integration of appropriate infrastructure and streamlined work processes.^16,19 Prioritised actions for change focused on improving operational, clinical and consumer interactions. This included the establishment of operational procedures across the service line along with department-specific guidelines addressing clinical care and safety issues. Access to familiar and accessible technology for staff and consumers was also prioritised, as well as procedures to facilitate flexible appointments (e.g. change in-person to telehealth) and efficient access to support services (e.g. interpreter services). To streamline operations across departments and optimise engagement with consumer groups, dedicated support roles, such as the nomination of staff champions were recommended.

All clusters except for ‘Strategic planning and evaluation’ were rated higher in importance than changeability. Given the fiscal climate post-COVID-19, it is understandable that goals requiring additional equipment or staff may be more challenging to achieve. However other clusters requiring limited additional resources such as the development of clinical models and guidelines were also rated at a similar level of changeability. While not explicitly explored, lack of knowledge and/or experience in telehealth is a known barrier to service engagement and enhancement.^22,23 Stage 6 of the concept mapping process, ‘Utilisation’ involves undertaking the change management process. It is acknowledged that execution of the prioritised goals into clinical practice will require the adoption of a planned implementation strategy. Frameworks that consider not only the adopters (e.g. staff and consumers), but also organisational (e.g. leadership and readiness for change) and wider system (e.g. regulatory) issues²⁴ such as the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) Framework²⁵ and Consolidated Framework for Implementation Research²⁶ have successfully guided multi-site/service AHP telehealth models.^2,27 Given this telehealth service functions within a large public health facility that supports a range of professions and clinical services, a multi-level implementation framework, such as these, will be required. In addition, the combined stakeholder support for service enhancements will also facilitate the use of known telehealth strategies aligned with these priorities such as nomination of staff champions,^28,29 standardisation of operational guidelines, and the development of staff training and consumer engagement procedures.²⁹ Ensuring a coordinated approach that incorporates stakeholder consultation across implementation, evaluation, and monitoring phases of the change management process will assist in the adoption and sustainability of these telehealth services enhancements.²⁹

It is acknowledged that this study was conducted in an AHP service line within a single public health facility with existing telehealth infrastructure. Different health services, funding structures and technology access/supports may reveal alternative priorities and results.

A dedicated effort is required to integrate and sustain telehealth services into mainstream clinical practice. Concept mapping was an effective approach to bring together key stakeholders and facilitate the identification and prioritisation of improvements required for AHP telehealth services. Results demonstrated the need to focus on improving staff support, consumer advocacy and engagement, and operational workflow processes to optimise service sustainability.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

Approval to conduct this study was granted by the Royal Brisbane & Women's Hospital (LNR/2020/QRBW/64414).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article

ORCID iDs

Clare L Burns

Michelle Cottrell

Ann Rahmann

References

Cottrell

Burns

Jones

, et al. Sustaining allied health telehealth services beyond the rapid response to COVID-19: Learning from patient and staff experiences at a large quaternary hospital. J Telemed Telecare 2021; 27(10): 615–624.

Thomas

Taylor

Ward

, et al. Beyond forced telehealth adoption: A framework to sustain telehealth among allied health services. J Telemed Telecare 2022: 1357633X221074499. https://doi.org/10.1177/1357633X221074499.

Fong

Tsai

Yiu

. The implementation of telepractice in speech language pathology in Hong Kong during the COVID-19 pandemic. Telemed J E Health 2021; 27: 3–38.

Reynolds

Awan

Gallagher

. Physiotherapists’ perspective of telehealth during the COVID-19 pandemic. Int J Med Inf 2021; 156: 104613.

Barton

Ezzat

Merolli

, et al. “It's second best”: A mixed-methods evaluation of the experiences and attitudes of people with musculoskeletal pain towards physiotherapist delivered telehealth during the COVID-19 pandemic. Musculoskelet Sci Pract 2022; 58: 102500.

Ward

Raatz

Marshall

, et al. Telepractice and dysphagia management: The era of COVID-19 and beyond. Dysphagia 2022.

Sjödahl Hammarlund

Nilsson

Idvall

, et al. Conceptualizing and prioritizing clinical trial outcomes from the perspectives of people with Parkinson's disease versus health care professionals: A concept mapping study. Qual Life Res 2014; 23: 1687–1700.

Yaphe

Adekoya

Steiner

, et al. Exploring the experiences of people in Ontario, Canada who have trouble affording medicines: A qualitative concept mapping study. BMJ Open 2019; 9: e033933.

Brons

Braam

Timmerman

, et al. Promoting factors for physical activity in children with asthma explored through concept mapping. Int J Environ Res Public Health 2019; 16: 4467

10.

Foley

Ward

Burns

, et al. Speech pathology service enhancement for people with head and neck cancer living in rural areas: Using a concept mapping approach to inform service change. Head Neck 2021; 43: 3504–3521.

11.

Ogden

Barr

Greenfield

. Determining requirements for patient-centred care: A participatory concept mapping study. BMC Health Serv Res 2017; 17: 780–780.

12.

Goff

Donaldson

De Oliveira Silva

, et al. People with knee osteoarthritis attending physical therapy have broad education needs, and prioritize information about surgery and exercise: A concept mapping study. J Orthop Sports Phys Ther 2022; 1–30.

13.

Bar

Mentch

. R-CMap – an open-source software for concept mapping. Eval Program Plann 2017; 60: 284–292.

14.

Rosas

Kane

. Quality and rigor of the concept mapping methodology: A pooled study analysis. Eval Program Plann 2012; 35: 236–245.

15.

Kane

Trochim

WMK

. Concept mapping for planning and evaluation. Thousand Oaks, CA: Sage Publications Inc., 2006, 216 p.

16.

Thomas

Haydon

Mehrotra

, et al. Building on the momentum: Sustaining telehealth beyond COVID-19. J Telemed Telecare 2022; 28(4): 301–308. https://doi.org/10.1177/1357633X20960638.

17.

Galpin

Sikka

King

, et al. Expert consensus: Telehealth skills for health care professionals. Telemed e-Health 2021; 27: 820–824.

18.

Edirippulige

Armfield

. Education and training to support the use of clinical telehealth: A review of the literature. J Telemed Telecare 2017; 23: 273–282.

19.

Speech Pathology Australia. Position Statement: Telepractice. 2014. Melbourne.

20.

Australian Physiotherapy Association. Telehealth guidelines: Response to COVID-19. 2020 [cited 2021 Jun 25], https://australian.physio/sites/default/files/APATelehealthGuidelinesCOVID190420FA.pdf

21.

Smith

Thomas

Snoswell

, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare 2020; 26: 309–313.

22.

Hill

Miller

. A survey of the clinical use of telepractice in speech-language pathology across Australia. J Clin Pract Speech Lang Pathol 2012; 14(3): 110–117.

23.

Raatz

Ward

Marshall

. Telepractice for the delivery of pediatric feeding services: A survey of practice investigating clinician perceptions and current service models in Australia. Dysphagia 2019; 35: 378–388.

24.

Greenhalgh

Shaw

Wherton

, et al. Real-world implementation of video outpatient consultations at macro, meso, and micro levels: Mixed-method study. J Med Internet Res 2018; 20: e150

25.

Greenhalgh

Wherton

Papoutsi

, et al. Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res 2017; 19: e367–e367.

26.

Damschroder

Aron

Keith

, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50–50.

27.

Ward

Burns

Gray

, et al. Establishing clinical swallowing assessment services via telepractice: A multisite implementation evaluation. Am J Speech Lang Pathol 2021; 30: 2456–2464.

28.

Wade

Eliott

. The role of the champion in telehealth service development: A qualitative analysis. J Telemed Telecare 2012; 18: 490–492.

29.

Kho

Gillespie

Martin-Khan

. A systematic scoping review of change management practices used for telemedicine service implementations. BMC Health Serv Res 2020; 20: 815–815.