The widespread development in wireless technologies and the advancements in multimedia communication have brought about a positive impact on the performance of wireless transceivers. We investigate the performance of our three-stage turbo detected system using state-of-the-art high efficiency video coding (HEVC), also known as the H.265 video standard. The system makes use of sphere packing (SP) modulation with the combinational gain technique of layered steered space-time code (LSSTC). The proposed three-stage system is simulated for the correlated Rayleigh fading channel and the bit-error rate (BER) curve obtained after simulation is free of any floor formation. The system employs low complexity source-bit coding (SBC) for protecting the H.265 coded stream. An intermediate recursive unity-rate code (URC) with an infinite impulse response is employed as an inner precoder. More specifically, the URC assists in the prevention of the BER floor by distributing the information across the decoders. There is an observable gain in the BER and peak signal-to-noise ratio (PSNR) performances with the increasing value of minimum Hamming distance ( To meet the unprecedented expansion in the demand for wireless services over the last decade, researchers need to strongly consider uplifting the communication systems . It is aOwing to the potential increase in wireless devices, the burden on available bandwidth is inevitable and therefore the compression of data is required to transmit and store expansive data. In the transmission of data, reliability at the destination is an utmost desire for suitable processing. Source codes are particularly employed for the compression of data, whereas channel codes primarily resolve emerging errors or at least assist in detecting errors for ensuring reliability . AccordiUntil now, turbo codes result in the highest performance and are deemed as the best codes with little required encoding and decoding complexity . The priContemporary cellular communication relies heavily on the multiple-input multiple-output (MIMO) technique for an enhanced performance by offering diversity and multiplexing gain improvements. Modern telecommunication is entirely based upon the mechanism of antennas to perform high speed and distant communication. One simple example of an antenna is a piece metal attached to a radio. With the aim of improving BER performance and attaining power reductions, the concept of MIMO can be viewed as an extension to smart antennas . The reaSphere packing (SP) modulation provides the maximum Euclidean distance and is becoming popular due to its high achievable performance when integrated with DSTS . SP moduG2 denotes the transmitted symbols by the two transmitting antennas. The columns in Equation (1) represent the spatial dimension while temporal dimension is represented by the rows for two successive time slots. The modulated signals for transmission are chosen from the available legitimate space time signals. Moreover, SP enhances the error resilience feature of the communication system by jointly designing the complex symbols [Here, (*) represents the complex conjugate of the symbol and  symbols .Authors in  investigthors in  performethors in . Moreovethors in  to gaugethors in  presentethors in  to find thors in  to investhors in . To boosthors in . Table 1In this treatise, we aim to attain a combinational gain using the merits of V-BLAST, space-time codes (STCs) and beamforming. These techniques are simultaneously employed in order to enhance the reliability of compressed information at the destination with lower rated in ,33. We hrated in . STCs arrated in . We haverleavers . We willInvestigating the performance of iteratively decoded LSSTC-SP scheme using state-of-the-art HEVC/H.265 source encoder.Quantifying the effects of SBC on the attainable performance of three-stage system via extrinsic information transfer (EXIT) charts for mobile video transmission over the correlated Rayleigh channel.Demonstrating the effects of Normally, resource allocation in communication networks is based on the scarcity of available bandwidth. We aim to offer a unique and effective strategy to ensure an efficient overall mobile video transmission by utilizing the H.265 source encoder. The novelty and major contributions of this research work are as follows:A three-stage serially concatenated iterative JSCD system is presented deploying the combinational gain technique  for the H.265 video coding standard. The three-stage iterative decoding system employs two iterations between the inner SP and intermediate URC decoder and the other iteration between the outer SBSD decoder and the intermediate URC decoder.N elements which are typically spaced at a distance of N elements is beneficial for introducing beamforming gain. On the receiving side, there are 4 antennas which effectively receives the signal from the wireless channel. The information is serial-to-parallel converted and the resulting symbol streams are then independently allowed to the corresponding STC with multiple AAs as discussed in [ussed in  for enhaussed in . The information bits are initially encoded by the HEVC encoder, and the data are compressed to an extent suitable for limited bandwidth transmission. HEVC/H.265 encoder is the latest standard adopted by researchers across the world and approved by The International Telecommunication Union-Telecommunication (ITU-T) standardization sector. The H.265 standard was particularly developed to enhance the compression efficiency of Advanced Video Coding (AVC)/H.264 standard, with the consistent video quality in both standards . It is wThe source encoded stream rding to , the SP th exist . MoreoveY = HWX + n, where X shows the transmitted signal vector, H represents the n indicates the additive white Gaussian noise vector as discussed in [n essentially have zero mean. The three-stage receiver model consists of the outer SBC decoder, the intermediate URC decoder, and the inner SP demapper. These three stages are respectively labelled as 1, 2, and 3 in a priori or intrinsic Information  values for a priori, a posteriori and extrinsic values respectively.The received signal vector is mathematically given by ussed in ,34. The rated in ,41. We ha priori LLR value a posteriori LLR value r) values are generated with the aid of maximum a posteriori (MAP) algorithm [r) are converted to The LSSTC decoder forwards the received complex symbols to the SP demapper in the LLR format . The inflgorithm  by deints). Subtracting the a priori s) information from s) generates s) which is interleaved via For the outer iteration, https://media.xiph.org/video/derf/. The rates of 15 frames-per-second (fps) and 64 kbps as the overall bitrate of Akiyo video after the encoding operation are considered for our simulations. Moreover, the H.265 standard is particularly designed for achieving the goals of parallel-processing, resilience to data-loss and coding efficiency [The picture parameter set used in H.264 stores shareable information which is rarely changed and is mostly used for decoding operation. The H.265 standard refers to this as the video parameter set (VPS).For the purpose of enabling video telephony and broadcast or streaming applications, the network abstraction layer (NAL) is designed which is an integral part of both the H.264 and H.265 standards.The concept of slices is adopted in both the H.264 and H.265 video standards. Slicing is normally used to avoid data losses by recovering the affected segments.Supplemental enhancement information (SEI) and video usability information (VUI) metadata are supported in both the H.264 and H.265 standards. These are put into the coded video as additional information and indicate the timing information, identify the colour space in the content, and provide other display related statistics.We have used the 45 176 × 144)-pixel quarter common intermediate format (QCIF) Akiyo video as test sequence and encoded the frames using the HM reference software for the H.265, also known as HEVC Test Model. The Akiyo video sequence is about a newscaster with few details in the backdrop and having minimal fluctuations. The Akiyo video test sequence is freely redistributed and publicly available at the Xiph.Org Foundation’s website. ficiency , to say -pixel quApart from above features, the H.265 standard also makes use of the inter/intra-prediction and 2D transform techniques, originally deployed in the H.261 standard. The inter and intra prediction techniques assist in determining a prediction residual, undergoing through block transformation, quantization, and entropy coding respectively for correcting the erroneous segments ,44,45. TSBSD exploits the natural redundancy to improve the convergence behavior of iterative decoding. SBSD gleans the residual redundancy for generating extrinsic LLRs, and hence beneficially transforms the coded video into short time frames, labelled as index i . This SBi ,48. Moreessed in .(2)Le1 in order to further enhance the iterative decoding performance. The learning process for channel estimation and its behaviour can be devised by allowing the LLR values to the CNN along with the iterative decoding process. Moreover, we expect to extend the existing HEVC setup to low bit rate 3D and multi-view video. Furthermore, we plan to simulate our proposed three-stage system using the H.266 codec (developed in mid-2020) for supporting ultra-high-definition video streaming. Interestingly, the H.266 codec further compresses the data stream with the employment of sophisticated encoders and decoders.This paper proposed an efficient three-stage system for avoiding the BER floor formation in most of the traditional two-stage systems. The design and performance curves for the three-stage wireless video communication system are provided. For efficient video transmission, we utilized the latest H.265 video codec. H.265 is widely adopted for achieving compression efficiency twice as much that of its precursor H.264 standard. The main constituents of the system were an SBC encoder, a URC precoder, and the modulation technique of SP. The URC assists in uniform distribution of information across the decoders. In addition, we investigated the performance of ISCD system with the combinational gain MIMO technique of LSSTC. More specifically, the system profited from the STC, V-BLAST and beamforming techniques. The system incorporated AAs for introducing transmit diversity gain. The BER and PSNR performances recorded significant improvements with the increase in


By combining video laryngoscopy and fiberoptic bronchoscopy, awake intubation can be performed more safely. The simultaneous display of bronchoscope and laryngoscope images on a single screen allows for safer conscious tracheal intubations. A multifaceted view of video laryngoscopy is necessary to ensure safety during awake intubation using a bronchoscope. We used the Glidescope 1 Core™ 10 VL/LoPro S1 , which allows for the insertion of a tracheal tube while the glottis is open (Video Nothing to declare.SU wrote the first draft. HO, HM, SN, HH, NS, TO, and RF critically revised it, and all authors read and approved the final version of the manuscript.The article does not contain any studies with human participants or animals.Written consent was obtained from the patient.Video S1Click here for additional data file.


Increasing coffee intake was inversely associated with risk of type 2 diabetes in Western countries. However, in China where coffee consumption and diabetes population has been growing fast in recent years, studies on the impact of coffee intakes on the onset of type 2 diabetes are lacking. This study attempts to determine the associations between coffee consumption and type 2 diabetes in Chinese adults.This longitudinal study analyzed 10447 adults who had participated in at least two rounds of the China Health and Nutrition Survey (CHNS), which is a survey database of multistage, random cluster process during 1993–2011. Coffee consumption and type 2 diabetes incidence were measured in the survey. Body mass index (BMI), age, sex, place of residence, waves, education level, smoking, drinking alcohol and tea drinking frequency were adjusted as covariate. We used longitudinal fixed effects regression models to assess changes within person.After adjusting confounding factors, lower risk of diabetes is observed among Chinese adults who drink coffee occasionally (Adjusted Odds Ratio (AOR)  = 0.13, 95% CI = 0.05, 0.34) and drink almost every day , compared with those who do not or hardly drink. In the subgroup analysis, among women aged 45–59 who drink coffee one to three times a week  and men over 60 who drink coffee almost every day , protective effects were found. For young men aged 19–29, drinking coffee almost every day showed a risk effect .Coffee drinking habit is an independent protective factor for adult on type 2 diabetes in China. And it varies among people with different ages and genders. The rapid growth of coffee consumption in China in recent years may help reduce the risk of type 2 diabetes, but at the same time, the risk of type 2 diabetes in adolescents needs attention. Type 2 diabetes (T2D) is the most common form of diabetes. It is a complex endocrine metabolic disease associated with eating habits and is considered to be a major health care problem in China at present , which hCompared to people who do not or hardly drink coffee, some health benefits and lower risk of chronic disease has been observed on people consuming 3–4 cups per day . CaffeinHowever, most of previous findings on the relationship between coffee consumption and health have been conducted in Western countries and among populations of European descent . This loThe research data comes from the CHNS , a publiThe CHNS is an ongoing, large-scale, longitudinal, household-based survey to investigate the health and nutritional status of the general population in China. The prospective household-based study surveyed nine provinces: Heilongjiang, Liaoning, Shandong, Jiangsu, Henan, Hubei, Hunan, Guangxi, and Guizhou. Provinces with diverse demography, geography, economic development, and public resource characteristics were surveyed by a multistage, random cluster process. The CHNS and the survey procedure has been described in detail elsewhere ,19. Ten http://www.cpc.unc.edu/projects/china/data/data.html, several data quality assurance methods were used. Trainings and field guides were distributed to data collectors and supervisors. Questionnaires were checked for consistency and completeness by supervisors at the end of every day. According to the unique id of each person, required data collections from different rounds were merged by using scripts of R language (version 4.0.3). Following data de-duplication and cleaning are mainly carried out using the R package data.table (version: 1.14.0). The whole process of data combination, cleaning, and analyzing was performed in a unified environment of R to ensure that every step of the data processing is fully recorded and can be reproduced.As the information provided by documents on CHNS official website Type 2 diabetes status was identified by the following question during the follow-up survey: “Has a doctor ever told you that you have diabetes?” If yes, “How old were you when you were told about the situation (diabetes)?” In the 2009 interview, blood sample of participants were collected in addition to the self-determine question in the survey, with which fasting plasma glucose and glycated hemoglobin (HbA1c) were checked. According to the 2010 American Diabetes Association criteria [criteria .In each questionnaire, participants were asked how often on average had they consumed coffee. The participants could choose from 9 responses of drinking frequency from drinking every day to 30 days without drinking. The coffee drinking behavior was divided into three groups: no or hardly drink, one to three times a week, drink almost every day.R was used for all data collation and basic statistical analysis. R package lme4 (version 1.1–23) was used to establish longitudinal fixed effects regression models to explore the crude and adjusted fixed effects between coffee drinking frequency and T2D. The individual itself and the group composed of sequences in multiple observations formed up two-layer model. Three models were evaluated:1) unadjusted crude associations were first examined, and 2) then these associations were adjusted for tea drinking frequency, BMI, age, waves, marital status, education level and place of residence. 3) Model 3 added smoking, drinking alcohol for further discussion.Odds ratios (ORs) with 95% confidence intervals (CIs) were presented to show the strength and direction of the association. The criterion for statistical significance was set at p < = 0.05. The variable assignment is listed in The crude analysis showed that compared with participants who do not or hardly drink a cup of coffee per month, for those who drink one to three times a week and more frequently, the odds of T2D are 87% and 50% lower (Crude Odds Ratio (COR) = 0.13, 95% CI = 0.05–0.31 and COR = 0.5, 95% CI = 0.4–0.64).After adjusting for confounding factors including tea drinking frequency, BMI, age, waves, marital status, education level and place of residence, the one to three times a week drinking behavior still exerted a statistically significant effect on T2D (Adjusted Odds Ratio (AOR) = 0.13, 95% CI = 0.05–0.34). Meanwhile, the inverse relationship  of drink almost every day is slightly smaller than the former.The specific results are presented in After further added other addictive common factors which is the habit of smoking and drinking alcohol, the statistical significance of coffee still stand and the correlation coefficient almost remains unchanged. The statistical significance of tea drinking frequency disappeared. This shows that the influence of tea drinking behavior on T2D might relate to other factors of lifestyle. As expected, smoking is a risk factor for T2D . However, on contrary to popular belief, drinking is a protective factor for T2D .The analysis based on different gender and age group implies the protective effect varies among people in This longitudinal study explored the association between coffee consumption and the prevalence of T2D in Chinese adults. The single-factor model of Model 1 shows that coffee consumption has a crude reverse correlation effect on T2D. The multifactor analysis includes drinking tea, BMI, sex, age, place of residence, waves, marital status and education level as covariates. Model 2 for all adults suggested that drinking coffee is a protective factor for T2D in China. We did not observe stronger protective effect on people who drink it almost every day than people who drink one to three times a week.The protective effect of drinking tea on T2D disappeared after smoking and drinking were added in Model 3. This may be related to more complicated lifestyle habits, which remains to be further studied and clarified. The protective effect of drinking alcohol on diabetes is consistent with some evidence ,28 that The models of subdivided participants revealed that the effect of coffee on T2D varies among genders and ages. For middle-aged women and elderly men, the habit of drinking coffee is a protective effect on T2D. However, among young men, those who drink coffee regularly are more likely to have T2D than those who hardly drink coffee. The impact of coffee on T2D in Chinese young people, especially young men, still requires further research.The reported association between coffee and T2D has not been entirely consistent across different countries and ethnicities. Studies performed in Dutch , Sweden Many studies have shown that acute caffeine ingestion reduces insulin sensitivity . This stCoffee consumption is associated with widespread metabolic changes, among which lipid metabolites may be critical for the anti-diabetes benefit of coffee. Coffee-related metabolites might help improve prediction of diabetes .Coffee interferes with glucose homeostasis, Long-term consumption of both coffee species reduced weight gain and liver steatosis and improved insulin sensitivity in the model of T2D .Chlorogenic acids may affect glucose absorption and subsequent utilization, the latter through metabolites derived from endogenous pathways or action of the gut microbiota ,35.The strength of this study is the largeness of sample, which means that the results of the multivariate longitudinal fixed effects regression analyses is stable. However, compared with related research performed in other countries, this study is limited by the contents of the CHNS questionnaire, and it does not consider other relevant information related to coffee consumption such as the type of coffee. Some studies have considered the interaction between coffee consumption and types of coffee and found that the protective effect of coffee on T2D is quite different by different kinds of coffee . In addiIn summary, a Coffee drinking habit is an independent protective factor for adult T2D. And it varies among people of different ages and genders. The rapid growth of coffee consumption in China in recent years may help reduce the risk of type 2 diabetes, but at the same time, the risk of type 2 diabetes in adolescents requires attention.


Early Infant Male Circumcision (EIMC) is part of sustainable HIV prevention strategies in Kenya. The goals of the national EIMC program are to circumcise at least 40% of all newborn male infants delivered at hospitals offering the service and keep the rate of moderate and adverse events below 2%.To determine the proportion of early male infants (age less than 60 days) born at hospitals in four counties of western Kenya who got circumcised and document the prevalence of adverse events (AEs) among those circumcised.A retrospective descriptive study involving all records for EIMC from 1st March 2014 through 31st March 2018 in four counties of western Kenya. Data analysis was done using EXEL to document proportion of facilities offering EIMC and compare EIMC uptake and outcomes in the four counties against the national goals for the program.A mean of 4.3% of total health facilities offer EIMC in the region. Siaya had the highest proportion of facilities offering EIMC while Migori had the lowest proportion. Uptake of EIMC was low at 17.4% for all male infants born, far less than the anticipated target of 40%. Average adverse event rates were 0.3%.EIMC uptake remains low in this region of Kenya due to small number of health facilities offering the service. The proportion of circumcised early male infants born at the target health facilities is below the national target of 40% even though the rate of adverse events among those circumcised is acceptable. Voluntary Male Medical Circumcision (VMMC) was introduced as a component of the national HIV prevention program in Kenya in the year 2008 after three randomized controlled trials in African men demonstrated that male circumcision reduces the risk of HIV acquisition by approximately 60%The aim of EIMC program in Kenya was to circumcise at least 40% of all early male infants who come into contact with EIMC providing facilities within 60 days after birth by 2019The aim of this study was thus to describe the uptake and outcomes of EIMC services in the four high-priority VMMC counties of western Kenya. The study mainly focused on the male infants born within the counties' health care facilities in the four counties who return for EIMC within 60 days after birth. The results of the study were compared against national program set targets as outlined in the Second Kenyan VMMC strategic plan (2014–2019)Study was conducted in four (4) counties of western Kenya, which were classified as high priority because of high HIV prevalence and inhabited by traditionally non-circumcising community. These counties are affiliated to the CDC western Kenya branch office.The target group was male infants born at the health care facilities in four counties and received EIMC within 60 days of birth at the EIMC accredited facilities within the four counties. Records of clients  who were born at the EIMC accredited facilities in the four counties during a 4-year period.The study included all male infants who received EIMC at 60 days after birth. Excluded were all male infants who received EIMC after 60 days of age, those with incomplete records (i.e. missing data) plus those born at home as well as outside the health care facilities in the four counties.Data was collected by review of EIMC records from March 2014 up to March 2018. The study had two sets of records 1) the total health facilities in each of the four counties plus the total accredited facilities certified to offer EIMC in these counties during the four-year period, and 2) EIMC data in the four counties for four years. Data was collected by two trained research assistants (RAs), one covering two counties. Each RA identified the relevant data sets for EIMC for their counties and obtained relevant data on a standard structured data collection sheet. The data was then forwarded via e-mail to the statistician at CDC office in Kisumu for entry, cleaning and analysis.Collected data was cleaned, coded and entered into an EXEL sheets for data analysis. The study variables of interest included:Number of male infants born at the EIMC target facilities in the four countiesNumber of male infants (aged less than 60 days) accessing immunization services who got circumcisedNumber of early male infants circumcised who developed AEsTotal number of health care facilities in each of the four countiesNumber of health facilities offering EIMC in each of the four countiesYear of circumcision Percentages and proportions of health care facilities offering EIMC against total health care facilities in each county were determined. In addition, proportions of early male infants circumcised against total number of early male infants born at the EIMC target facilities were determined. The values generated were measured against the national strategic objective targets of circumcising at least 40% of all male infants born at the EIMC providing facilities within 60 days after birth. The rate of occurrence of AEs was determined by summing up all the reported cases of AEs against the total number of circumcisions performed. A table and graphs were generated to show the trends in uptake and outcomes of the various EIMC interventions in the four counties over the 4-year period.The study was approved by institutional ethical research committee (IREC) at Moi University and permission to review ministry of health data base obtained from EIMC implementing partners before data collection began. The study did not have informed consent processes since there was no direct contact with patients and personally identifiable information was de-identified before analysis. It was a less than minimal risk study, the only possibility being breach of confidential patient information, and so utmost care was taken to safeguard privacy and anonymity of client data. Data sharing was only among the study team members plus the sponsors of research.The study sample was the total number of male infants born at the healthcare facilities in the four counties of western Kenya over a four-year period. Their mean age at the time of EIMC was 22.6 days. In Although the Kenyan VMMC strategic plan (2014–2019) had indicated that EIMC roll-out would begin in 2014 and proceed till 2019 According to Another factor that could have led to low uptake of EIMC services is lack of access. The results show that the number of health facilities offering EIMC represents a very small proportion of the total health facilities in the counties (range=4.9–5.8%). The trend in EIMC uptake also showed that this number of health facilities offering EIMC remained fairly constant in all the counties during the study period and there were few new facilities being upgraded and accredited to offer EIMC from 2015 to 2018. These reasons could have contributed to the low uptake of EIMC services in this regionThe EIMC uptake in this program is still low against the expected program target, even though the rate of AEs among those who received EIMC is below the expected cut-off of 2%. More efforts, therefore, have to be put in place to enhance uptake of this service. The study had a number of limitations. First of all, this being a retrospective study, there was the inherent weakness of missing and/or incomplete data. Therefore, all patient records with missing data were excluded and data analysis was adjusted according to completeness of information obtained.


Scotland—a country of 5.5 million people—has a rugged geography with many outlying islands, creating access challenges for many citizens. The government has long sought to mitigate these through a range of measures including an ambitious technology-enabled care program. A strategy to develop a nationwide video consultation service began in 2017. Our mixed methods evaluation was commissioned in mid-2019 and extended to cover the pandemic response in 2020.To draw lessons from a national evaluation of the introduction, spread, and scale-up of Scotland’s video consultation services both before and during the pandemic.Data sources comprised 223 interviews , 60 hours of ethnographic observation (including in-person visits to remote settings), patient and staff satisfaction surveys , professional and public engagement questionnaires (n=5400), uptake statistics, and local and national documents. Fieldwork during the pandemic was of necessity conducted remotely. Data were analyzed thematically and theorized using the Planning and Evaluating Remote Consultation Services (PERCS) framework which considers multiple influences interacting dynamically and unfolding over time.By the time the pandemic hit, there had been considerable investment in material and technological infrastructure, staff training, and professional and public engagement. Scotland was thus uniquely well placed to expand its video consultation services at pace and scale. Within 4 months (March-June 2020), the number of video consultations increased from about 330 to 17,000 per week nationally. While not everything went smoothly, video was used for a much wider range of clinical problems, vastly extending the prepandemic focus on outpatient monitoring of chronic stable conditions. The technology was generally considered dependable and easy to use. In most cases , patients reported no technical problems during their postconsultation survey. Health care organizations’ general innovativeness and digital maturity had a strong bearing on their ability to introduce, routinize, and expand video consultation services.The national-level groundwork before the pandemic allowed many services to rapidly extend the use of video consultations during the pandemic, supported by a strong strategic vision, a well-resourced quality improvement model, dependable technology, and multiple opportunities for staff to try out the video option. Scotland provides an important national case study from which other countries may learn. The first documented video-mediated medical consultations in health care were conducted in the 1950s via closed-circuit television -7. The vPrepandemic research on the acceptability, effectiveness, and cost-effectiveness of video consultations seemed to convey a positive message but was potentially misleading. Numerous research trials , in which a digitally confident and low-risk sample of patients selected from a much more diverse clinic population was randomized to continuing their usual outpatient care or trying the video option, usually showed that the latter group did no worse clinically and were no less satisfied than the former, and that costs (when measured) were similar -14. AlmoIn published research trials of video consultations, the service was usually available only as part of the trial and discontinued thereafter, so the challenges of embedding it in business-as-usual were never addressed. Any conclusion that video is effective, acceptable, and safe was therefore naïve and premature. To “work” in the real world, video consultations require new infrastructure, new technologies, new clinical and support roles, new organizational routines, new approaches to privacy and information governance, new clinical techniques , and new payment and reimbursement frameworks—not to mention measures to improve the digital skills of staff and patients and mitigate digital exclusion -20. GiveEarly in the pandemic, an overview pointed out that despite the technical potential of remote forms of consulting to help address infection control,“[m]ost countries … lack a regulatory framework to authorize, integrate, and reimburse telemedicine services, including in emergency and outbreak situations”  (p1). BuIn these early months of the pandemic, politicians, policymakers, and the lay press across different countries and regions all emphasized the role of new modalities such as video and e-consultations in this unprecedented service change -33. But An important question for researchers is why, even in the context of an unprecedented global emergency, establishing and sustaining video consultations as business-as-usual in a mainstream health service has proved such a stubborn challenge. Rather than analyze failures, we have chosen to consider the case of Scotland, UK, as—broadly speaking—a success both before the pandemic  and during it .In telling Scotland’s story, we draw inspiration from a theoretical approach called appreciative inquiry, a form of action research or action evaluation which explicitly seeks to highlight, learn from, and reinforce the positive—things that went right, preconditions that helped, people who made a difference, and so on—while also identifying and learning from less successful aspects of the case . AppreciThe aim of this study was to draw lessons from an in-depth study of one country that could inform video consultation services and policy decisions more widely. In the remainder of this paper, we first give a historical background to the Scottish case. In the “Methods” section, we describe our aims, study setup, research questions, theoretical framework , data sources, and methodological approach for our national evaluation of video consultation services both pre- and peripandemic. We then describe our findings, structured along the 7 domains of the PERCS framework. Finally, we discuss the Scottish case in the context of the wider literature, highlighting learning points for other countries.Scotland (population 5.5 million) is 1 of the 4 jurisdictions in the United Kingdom with a land area only 40% smaller than England (population 56 million). Much of it is mountainous and rugged with lakes (known as lochs), rivers, and offshore islands. Scotland thus shares some of the geographical challenges of remote Scandinavian regions, with some journeys involving a combination of land, water, and air. Scotland’s health service is organized separately from those of England, Wales, and Northern Ireland. Health and care services are mainly delivered by 14 territorial health boards and are underpinned by a strong public-sector ethos which emphasizes professionally led quality improvement and reducing inequalities .There has long been a strategic intent in Scotland to support and extend remote consulting options, including via video. This was advocated from 2008 through Scotland’s eHealth Strategy ,43 and eThe video consulting workstream of the TEC Programme was seen as enabling pooling of expertise and provision across the country to ensure a high-quality patient experience. Initially, this involved various pilot studies which used different video technologies, including Cisco Jabber and Polycom devices, before the TEC team decided in 2015 to introduce a more bespoke product (Attend Anywhere), described below. Based on the success of a pilot co-design and quality improvement program in one health board (Highland) in 2017, the video consulting service using the Attend Anywhere platform was branded nationally as “Near Me” (a name chosen by a patient). In November 2018 the TEC Programme launched a £1.6 million (US $2.3 million) “scale-up challenge,” to support wider rollout across all health boards. By February 2020, all 14 health boards and the Golden Jubilee National Hospital  were enrolled in the program.Even before the pandemic, the Near Me video service had been adopted by about 180 services, spanning 35 different clinical specialties, albeit at different levels of implementation. But actual use of video within most of these services remained relatively low, with many clinicians describing their use of it as “ad hoc” rather than business-as-usual. Nevertheless, the scale-up effort continued to progress and established a strong national profile, steadily working through regulatory, infrastructural, and operational challenges. The rationale for scaling up Near Me was initially reducing patient travel and improving access and service efficiency . Video cIn March 2020, when the COVID-19 outbreak reached Scotland, most routine and nonurgent care in both primary and secondary care was halted. Space and staffing were repurposed to support the pandemic response. Rollout of the Near Me video service was accelerated via a 12-week scale-up plan, led by a rapidly assembled national implementation team within the existing TEC Programme. Staff were drafted in from across Healthcare Improvement Scotland , the Scottish Access Collaborative (a government program to sustainably improve waiting times for non-emergency procedures), and the Care Inspectorate . They prepared guidance and resources for deployment of video consultations across a range of health and care settings and built links with other key government departments—for example, with the Primary Care Division which covered general practice. National-level groundwork and strategic planning over the previous 2 years to create technical infrastructure, service readiness, and positive attitudes helped services transform, at pace and scale, to a remote-first mode of operating as the pandemic took hold.Following this 12-week scale-up, an engagement exercise was undertaken with various service teams to consolidate implementation plans for the video service going forward. A key element of this was the need to streamline and coordinate activities that had been undertaken in the immediate response, as well as leverage learning and resources developed. More broadly, health boards were required to produce recovery plans for clinical services during and beyond the pandemic, as part of the Scottish Government Re-mobilise, Recover, Re-design framework .Evaluation and system learning were built into the Scottish Government’s strategy both before and during the pandemic. Below, we describe the methods and findings of a commissioned evaluation.research aim was to draw generalizable learning from an in-depth analysis of this case.This commissioned evaluation aimed to highlight—at individual, organizational, and system level—how clinical and nonclinical staff adapted their practices and systems to accommodate and optimize the use of remote consultations both before and in response to the pandemic, and to inform policy going forward. As noted above, our The initial evaluation contract was awarded in July 2019 by competitive tender following a public call for proposals. A follow-up contract was awarded in June 2020 using COVID-19 emergency procurement regulations. Ethics approval was obtained from London – Camberwell St Giles Research Ethics Committee (ref 19/LO/0550) and the NHS Research Scotland Permissions Coordinating Centre. A small advisory group was set up within the Scottish government to oversee the project. Progress of the second phase of the evaluation was also monitored by an external advisory group with wide stakeholder representation and a lay chair established to oversee a number of rapid-response research studies on remote care occurring during the pandemic. Fieldwork was conducted by JW and TG.Our research questions were, in relation to this national case study:What were the multiple interacting influences  on the uptake, implementation, scale-up, acceptability, effectiveness, and appropriateness of video consultations?What was the impact of the COVID-19 pandemic on the scale-up effort?What can we learn from this case about the kind of knowledge, capabilities, and infrastructures needed to support the introduction and use of video consultations in different parts of a public-sector health service?conjunctive theorizing—that is, producing an account which weaves multiple themes and influences together in a way that conveys the complexity, historical emergence, and inherent messiness of the case and draws attention to the interdependencies between different aspects of it. Appreciative inquiry applies this methodology to largely successful cases to gain insights particularly—though not exclusively—from what went well [This was a mixed methods naturalistic case study, using an “n of 1” hermeneutic approach drawing on the theoretical work of Flyvbjerg , Stake , Tsoukasent well .Development and refinement of the PERCS framework  are descData were collected in 2 phases, before and during the COVID-19 pandemic. The periods and data sources for the 2 phases are presented in In sum, our data set comprised 223 interviews with patients, staff, technology providers, and policymakers . When interviewees talked in the abstract about problems and challenges, we asked them to describe specific examples of these. Qualitative data collection was conducted within a subsample of health boards purposefully selected to explore variation in geography  and progress in the implementation and uptake of video consultations before and during the pandemic.In addition to qualitative interviews and fieldwork, analysis was informed by evaluation data captured nationally by the TEC team in both phases of the study. A short online survey was completed by patients and clinicians immediately after each video consultation. In phase 1, the patient survey questions focused on experience and perception of technology . In phase 2, we added a 6-question validated patient enablement instrument to assess perceived quality and usefulness of the clinical aspects of the consultation . The onlA public engagement exercise conducted by the TEC team during the pandemic explored perspectives on the mainstreamed use of video consultations during and beyond the pandemic. This included online and paper questionnaires with members of the public (n=4197) and care professionals (n=1203), which were disseminated through a range of national and community networks.Data on the uptake and use of the Near Me service were captured nationally during Phase 1 and Phase 2, spanning 12 months (January-December 2019) and 9 months (January-September 2020), respectively. The activity data were captured through the Attend Anywhere platform, as opposed to NHS systems, so it was not possible to establish the proportion of video in relation to other appointment types .Data were pseudonymized by giving each participant a different name. A spreadsheet containing real names and pseudonyms was stored securely in accordance with General Data Protection Regulations (GDPR). Interviews were anonymized and stored securely and selective sections transcribed. Interviews were not fully transcribed, partly for resource reasons and partly to avoid loss of overview, because salient issues were often captured succinctly in field notes. We returned to the audiotape to obtain a verbatim record where needed. We organized and gained initial familiarity with our qualitative data by organizing field notes and interview notes into an Excel spreadsheet to identify emerging themes. Each row represented an interviewee and each column represented a thematic category. We then considered each thematic category in turn, along with interactions and interdependencies. Following this familiarization phase, we undertook a more theoretically driven analysis using the PERCS framework described above so as to highlight how multiple influences interacted dynamically and unfolded over time.Quantitative data were used to illustrate and affirm the narrative and inform ongoing data collection and analysis. Uptake and use across different health boards and specialties (and how these changed over time) were used to provide a national picture on the pace and scale of rollout, and highlight areas of focus for ongoing fieldwork and interviews . Survey and questionnaire data were analyzed using descriptive statistics in order to provide a national-level account and explore perspectives across different specialties and regions.Phase 1 (before the pandemic) of the evaluation generated over 300 pages of interview transcript, field notes, and document excerpts as well as raw quantitative data on staff and patient experience. At the time, our analysis  focusedIn the prepandemic phase, we were particularly struck by 3 things. The first was the focus on region-by-region quality improvement. As described above, there had been long-established strategic drivers for Near Me in Scotland, with strong national policy support for such systems to reduce the human, financial, and environmental burden of travel. Commencing 2017, in one of Scotland’s largest geographic regions (Highland), systematic efforts had been made to work collaboratively with clinicians and patients to implement a video consultation service. By 2019, this work was well underway in Highland, led not by a technical expert but by a clinician (pharmacist) who was well-regarded regionally and had previously been trained in—and personally inspired by—the system-wide approach to quality improvement promoted by the US Institute of Medicine . BuildinThe second striking feature of the service in late 2019 was the emergence of different service models reflecting Scotland’s remote geography. At that time video consultations were rarely used in primary care, as almost every citizen lived fairly close to a local general practice and doctors in remote areas were generally happy to do home visits to those unable to travel to surgery. Video was largely a secondary and tertiary care service taken up in particular by remote regions. We identified 3 different models of use:Hub-home, in which the clinician connects from the clinic (hub) to the patient at home ;Dyadic hub-spoke, in which the clinician in a specialist clinic (hub) connects to the patient in a remote health or care site ;Triadic hub-spoke, in which the clinician in a specialist clinic connects to the patient in a remote health or care site with an additional staff member present.Contemporary images of video consultations generally depict some variant of the hub-home model . This was extremely rare in our data set. Most video consultations in the prepandemic phase were organizationally far more complex—involving a triadic hub-spoke model in which a specialist in a secondary or tertiary care center connected with a remote hospital, primary care clinic, or care home and the patient received both technical and clinical support from a staff member such as a nurse, general practitioner (GP), or health care support worker. As we describe below, this unusual and resource-intensive arrangement produced challenges both at the time and—even more so—once pandemic-related infection control measures were imposed.most services still offered few video appointments and many offered none at all.The third striking aspect of the Scottish Near Me service was its asymmetric development, driven in some places by particular local enthusiasts and thwarted in other places by lack of them. Often, a video service had been established serendipitously—for example, as a specialist consultant who moved away sought to keep some clinical contact with their patients—and maintained through strong working relationships between key members of staff. This patchwork nature of video consultation services had advantages and disadvantages. On the one hand, it reflected the Scottish Government’s enabling (rather than command and control) approach, in which professionals could be creative and locally adaptive. On the other hand, the lack of a centrally mandated policy meant that despite Scotland’s relative success, When we returned—using virtual methodologies—to explore the response to the pandemic, our data confirmed a rapid expansion of the service . In 2019Although the pandemic saw a significant shift in the use of Near Me at a national level, the extent of this change varied across care settings. For instance, while many general practices introduced the Near Me service model, most used it infrequently and ad hoc, so that general practice as a whole accounted for only 22.55%  of all video consultations in Scotland. Among hospital and community specialties, the services accounting for most video activity were psychiatry, psychology and community mental health , physiotherapy , and pediatrics .In the analysis below, we present findings from each domain of the PERCS framework. Interview quotes are provided by domain in Prior to the pandemic, almost all new consultations in secondary care were face to face, in order to establish a clinical relationship, undertake a full physical examination, and conduct baseline assessments . Video consultations were used primarily for routine follow-up of chronic, stable conditions, especially to convey test results and affirm that the patient remained asymptomatic , community mental health follow-up , and postoperative follow-up. In many such situations, clinicians saw value in “eyeballing” the patient  to assess their general health. Some remote physical examinations were possible, especially by experienced practitioners Q1b in .feel a lesion as well as see it , which precluded video examination.During the pandemic, use of video was extended to embrace a much wider range of clinical conditions and reasons for consulting. This was driven by a concerted national effort to maintain the provision of priority clinical specialties , as well as local teams seeking to maintain some service provision across a range of different specialties. Most of these required no formal physical examination. Video was noted to be very useful in psychiatry, psychology, counseling, respiratory medicine, and speech and language therapy, where visual, nonverbal communication was important and personal protective equipment might interfere Q1c in . Some clSome conditions for which a visual examination was crucial were considered unsuitable for video consultations. For skin lesions, for example, the variable quality of the video image transmitted from a patient’s device was not always adequate to make a confident diagnosis; instead, patients were often encouraged to obtain and upload a high-quality still photograph taken in good light. This approach also allowed the image to be stored and, where necessary, sent on for a specialist opinion. Most acute ophthalmology consultations required slit-lamp examination or fundoscopy (use of high-intensity light and magnification to see inside the eye) even when there was an evident lesion on the eye . While video was used for remote examinations by ophthalmologists, patients still needed to be physically co-present with the optometrist in order to capture magnified images of the eye through specialist equipment. In sexual health, use of video and still images was limited by legal and regulatory restrictions on transmission of intimate images (and by practitioners’ discomfort about exchanging such images).Both before and during the pandemic, video consultations were widely viewed as clinically less appropriate for poorly defined and less predictable conditions, rare conditions , life-changing diagnoses, planning of major interventions , unstable or unpredictable psychiatric conditions , or when the patient would need to attend in person anyway to have tests or collect medication. The threshold for offering such patients a remote consultation changed, however, as the risk–benefit balance was dramatically altered by the pandemic. In the context of pandemic restrictions, GPs considered telephone adequate for most problems in known patients, as they felt they rarely needed to rely on visual assessment or physical examination. But video was sometimes considered crucial for visual assessment to exclude rare but potentially serious acute problems such as infection Q1d in .Primary care is traditionally the “risk sink” of a health service: most new problems are low risk and self-limiting, and potentially serious symptoms or signs can be observed and referred on as needed. During the pandemic, GPs talked of the difficulty in managing risk without the option of bringing the patient in for a face-to-face examination, especially because secondary care colleagues did not always trust an assessment made by telephone. One experienced GP felt they had picked up a possible malignancy purely from the history, so referred the patient on the basis of that, but the patient was “triaged” at the secondary care end and the appointment refused Q1e in .Our prepandemic evaluation identified numerous comorbidities and preexisting conditions which affected patients’ ability to use the video technology. These included temporary or permanent confusion or other cognitive limitation, visual impairment, or serious anxieties about the technology . But more commonly, the barrier to using video was the patient’s general level of debility Q2a in .Many patients with deafness and partial hearing loss found remote consultations by telephone impossible, while those able to lip-read or use the chat function often welcomed the option of video. Professional interpreters using the British Sign Language were available for some via remote triadic consultations, depending on the availability of interpreters and organizational structures in place to coordinate this. During the pandemic, patients with hearing impairment—and staff—were greatly handicapped by the requirement to use face coverings in face-to-face settings, making a video consultation a more attractive option Q2b in .Interpreting services for patients who spoke limited English were rarely available by video before the pandemic, due to logistical challenges of bringing the interpreter into a 3-way call. However, remote interpreting services gained impetus during the pandemic, when resources were directed into meeting the technical and logistical challenges  to establish or strengthen a personal relationship with the clinician, and sheer convenience .During the pandemic, concerns about infection risk became over-riding for most, leading many people to try video consulting for the first time. Findings from the public engagement survey indicated a high level of support for continuing remote consulting beyond the pandemic, partly because people were now familiar with this medium and partly due to on-going anxieties about risk of infection.Our prepandemic visits to Scotland highlighted the very remote settings in which some people lived. Transport links were sometimes few and unreliable , and staff as well as patients spent many hours (and sometimes whole days) traveling to and from clinics. Even before the pandemic, many people described how video consultations had transformed their lives simply by saving travel time. But connecting from home was far from an instant option for some patients. Many homes in remote areas were small, of basic construction, and had limited privacy. In some communities , there were high levels of poverty and deprivation. In the public engagement survey, respondents’ reported “very significant” barriers to uptake including lack of access to an appropriate device , poor internet connectivity , restrictions on mobile data packages , and lack of private space at home .Requirements for physical distancing and managing risk of infection during the pandemic required a shift from the triadic hub-spoke model of video consulting to a hub-home model, for which neither the patients nor the service were fully prepared. Failed attempts at video consultations to patients affected by digital poverty  were common and frustrating Q3a in . Video cPatients with low digital literacy or confidence sometimes benefited from on-hand carer support for video consultations; those lacking such support were often limited to telephone. Carer support included setting up and troubleshooting the video link, adjusting the camera angle to facilitate a remote physical examination, preparing and overseeing a child’s appointment (while enabling rather than interfering with the direct clinician–child interaction), and assisting with translation or communication Q3b in .As we have shown previously, supporting a relative’s remote clinical examination can be emotionally as well as technically challenging, because it may involve complex negotiations between carer and patient about the balance between assistance and autonomy . During An established clinical relationship, based on previous face-to-face encounters, made clinicians and patients more relaxed about video consultations and allowed clinicians to tolerate the higher levels of uncertainty associated with this medium. Prior to the pandemic, most clinicians liked to have an initial face-to-face consultation to establish rapport and confirm suitability of video for follow-up appointments. Initially, the default in all services was for first assessments to be done in person, but the pandemic required many new referrals to be assessed via video. While these posed challenges , many informants told stories of how such interactions had gone surprisingly well.Mental health specialties in particular considered video important for communicating Q3c in . A recurPerceptions on how remote consulting altered the relationship and interaction between patients and clinicians were nuanced and highly contingent upon clinicians’ interaction styles, perceived value of tactile information and facial expression, and the clinical context of the encounter. Some emphasized the therapeutic value of the in-person physical examination and regretted the loss of such contact during the pandemic Q3d in . Others Video was occasionally advocated for more paternalistic reasons. One medical consultant, for example, considered that teenagers did not take telephone consultations seriously and were likely to “pay attention” more if they were seen by video.Attend Anywhere, the technology used for Near Me across Scotland, is an internet browser–based video technology that can be accessed by a staff member on a work computer or a member of the public using their own device. One defining feature is its “inbound” workflow, which seeks to emulate how patients physically attend their appointments. For example, a single button on a website (or consistent weblink address on an appointment letter) offers a one-stop “virtual front door” for patients. On clicking that link, the patient enters a “virtual waiting room” , before being invited into the clinician’s virtual consulting room. Because Attend Anywhere does not require the downloading of software or creation of user accounts, it is easier for patients to use securely. The system has also been designed specifically for health and care, with a strong information governance model that was reviewed and endorsed nationally. This helped avoid information governance restrictions which prevail in many health care organizations.In our prepandemic evaluation, the Attend Anywhere technology was generally considered by staff and patients to be dependable and to produce high-quality video and audio. In most cases , patients reported no technical problems during their postconsultation survey. Of those reporting technical problems, the issues mainly related to internet connection and audio–video quality , as opposed to complete technical failure or usability issues. Staff and patients told us that ease of use was partly due to the well-designed software, also partly because many services had invested in high-quality peripherals such as screens and noise-cancelling microphones. Additional data from postconsultation surveys are provided in During the pandemic, 2 problems occurred. First, the shift to hub-home care models (see above) meant that the connection came to depend heavily on patient connectivity and device , leading to loss of video or audio connection or awkward lag Q4a in . Second,The video connection also depended on other technical systems, particularly for accessing the virtual waiting area. For example, text-messaging systems through the electronic booking systems to provide the patient with the URL were prone to error during rapid rollout, sometimes sending incorrect links to patients.When the video connection failed, telephone was used—fairly unproblematically—as a backup.Despite these challenges, patient survey responses remained generally positive. Most  reported no technical problems. Of the remainder, most problems were similar to those encountered in the prepandemic evaluation .The functionality of Attend Anywhere was considered good by most interviewees. Clinicians particularly liked the virtual waiting room and the option for screensharing Q4b in . This fuWhile Attend Anywhere was unfamiliar to most patients, the “inbound” workflow with a single point of entry and virtual waiting area made sense to patients because (they told us) using the technology “felt like” going into a clinic and physically sitting in a waiting room—a finding that others have also observed . There wA national policy decision to provide Attend Anywhere to all NHS organizations, alongside financial investment in the model in 2018, strengthened the organizational incentives to expand use of the technology prior to the pandemic. At the start of the pandemic, central procurement of Attend Anywhere was further extended by 2 years. Significant challenges were faced in resourcing laptops, video cameras, and audio equipment in the face of national shortages and disrupted supply chains during the pandemic. But because Attend Anywhere is an encrypted browser-based technology, some staff could make use of personal devices to run video consultations.Staff attitudes toward video consulting varied considerably, especially before the pandemic. Most clinicians we spoke to who had used Near Me had positive things to say about it, describing it as a significant way of improving patient access and experience by reducing the need for travel, providing faster and more direct access to specialists, and helping overcome reluctance to visit clinical spaces. Some clinicians, who used video never or rarely before the pandemic, depicted such services as unprofessional or unsafe Q5a in . But intMany clinicians talked about still being on a learning curve about when to offer the remote option and how to conduct such consultations effectively, including adapting ways of interacting with patients to take account of the physical and symbolic differences of the virtual environment Q5c in .The shift to video was not universally welcomed. Some staff felt its continued use beyond the pandemic was a retrograde step because it was less professionally fulfilling Q5d in .Before the pandemic, the use of video consulting was almost never spoken of in relation to staff well-being (with the exception of saving travel time). During the pandemic, video consultations were seen, on the one hand, as protecting staff—especially vulnerable ones—from risk of infection. On the other hand, they were described as more cognitively demanding and tiring than face-to-face ones. In a few cases, the clinician described becoming unwell during a video consultation Q5e in .The general innovativeness and digital maturity of health care organizations had a strong bearing on their ability to introduce, routinize, expand, and evaluate their video consultation service. In this regard, the nationwide effort by the Scottish Government to strengthen digital infrastructure over the previous 10 years was evident. Many, though not all, organizations had good broadband connection, adequate hardware, and sufficient numbers of trained staff to implement the technology. In many specialties, the equipment had been installed but had not been routinely used until pandemic pressures created an impetus.Developments before the pandemic revealed the importance of equipment setup and availability. This included dual screens, high-quality cameras and noise-cancelling microphones and speakers, as well as specialist equipment . Much work had gone into these details alongside the rollout of Near Me in 2018-19. However, during the early stages of the pandemic, demand for this kit soon exceeded supply, especially because infection control protocols prevented sharing between staff. Some ran short and had to rely on the phone.Video consulting relied on other technical systems, such as electronic booking and secure asynchronous communication channels with patients . Digital maturity, in this regard, was the extent to which standardized processes had been established for the smooth running and reconfiguration of appointment schedules to accommodate different modalities. The rechanneling of IT and outpatient resources during the pandemic helped address these challenges, but staff in some settings described various glitches, such as patients entering incorrect virtual waiting areas, due to rapid restructuring of administrative workflows and systems Q6a in .Prepandemic infrastructure strengthening through the TEC Programme had mainly focused on outpatient hospital sites, which were able to scale-up quickly as the pandemic hit. By contrast, general practice services had had little interest in video consultations before the pandemic and had to be rapidly set up in early 2020. Because of shielding, and also because clinic space was repurposed , many general practice staff worked from home. Despite input from mobile IT teams to install the necessary equipment, this remote working did not always go smoothly Q6b in .A major challenge across all sites was establishing adequate space and equipment for a video consultation. During the pandemic, staff worked pragmatically and adaptively, with technology to hand. Particularly for the larger city hospitals, moves toward hot-desking and shared office space were not conducive to the expansion of video services, because open-plan working encroaches on privacy and may require the clinician to wear a mask.Some staff described logistical barriers to establishing and running a remote consultation, notably requesting and obtaining blood test results from the patient’s local primary care practice, transmitting a prescription to the patient’s local pharmacy when the patient was not there to collect it in person, providing patients with printed information sheets, or obtaining written consent Q6c in .Many of these logistical issues required a redistribution of resources across the system . The expansion of video appointments also required new ways of working and sharing data across departments and with patients . While these changes were initially developed (and resourced) as an interim “workaround” measure, there is both enthusiasm and concern for sustainability of these practices.Before the pandemic, efforts to introduce and use remote services often stalled because of staff shortages  or general lack of resources. Attempts by IT and service managers to set up remote services and embed them in business-as-usual were dependent on clinicians who were willing to join the change effort, use the technology, and consider working in a different way. Such individuals were relatively rare . The reWe found in our prepandemic evaluation that both dyadic and (even more so) triadic hub-spoke models raised logistical challenges and required various kinds of double-handling . In some remote sites, there was much redundancy ; in others, a lone staff member had to juggle multiple roles Q6d in .Because much of this double-handled activity related to outpatient consultations or cold surgery, it was stalled during the pandemic. It is unclear how, as video consultation services expand beyond the pandemic, this issue will be resolved.All the organizations we studied were committed to a policy of inclusion. Service teams were encouraged to ensure that new remote models did not disadvantage people in relation to service access and allowed patients to exercise choice where clinically appropriate.During the pandemic, patient choice was heavily constrained by infection control protocols, a measure that created huge challenges for ensuring equity of access. Some of our respondents were keen that video should not be the default option for everyone going forward Q6e in .The Scottish Government’s longstanding commitment to using technologies to achieve high-quality, accessible, and equitable care and contributing to a low-carbon future created an important national-level context for the introduction and mainstreaming of video consultations. While remote areas had limited or no broadband access, this was improving as a result of a policy push for connectivity. However, there was no strong tradition of digital communication . When the pandemic hit, the Near Me service was immediately mandated across the country, allowing rapid and consistent implementation locally and regionally Q7a in .Also important was engagement of professional bodies such as Royal Colleges, who endorsed the TEC Programme’s vision and guidance documents from an early stage. Proactive communication between government and professional bodies ensured that frontline clinicians believed that the changes were professionally endorsed and led rather than imposed by central government. In addition, the TEC team worked with NHS National Services Scotland  to review and monitor network bandwidth capacity for the rapid expansion of video, and sought data protection approvals at a national level to provide confidence and continuity across local organizations.There was a concerted effort at national and local level to support collaborative learning and interorganizational support. This included shared learning within specialties at national level (supported by NHS Education Scotland) and board-level collaboration between departments about local processes Q7b in . As wellThis is a mixed methods case study of the development and pandemic-driven scale-up of video consultation services across Scotland. Using the PERCS framework, we have mapped a complex data set of qualitative and quantitative findings to explain multiple interacting domains of influence. Before the pandemic, a national program to extend a service that had been successful in local pilots was already underway, driven by an ethos of collaborative quality improvement, reducing inequalities, and achieving cross-government low-carbon goals. By the time the pandemic hit, there had been considerable investment in material and technological infrastructure, staff training, and professional and public engagement. Scotland was thus uniquely well placed to expand its video consultation services at pace and scale, resulting in a dramatic increase in number of services using video. While not everything went smoothly, video consultations became available as business-as-usual for a much wider range of clinical problems, vastly extending the prepandemic focus on outpatient monitoring of chronic stable conditions.The great strength of this study is that, somewhat serendipitously, we had built a good working relationship with the Scottish Government and many regional implementation teams just before the pandemic hit, and were able to mobilize quickly to undertake a second phase of the evaluation. This meant that—perhaps uniquely in any country—we obtained both pre- and peripandemic data of various kinds. We were also undertaking other research on remote consultations across the UK and developing the PERCS framework, which proved useful for explaining and organizing multiple streams of data.The limitations of this study are threefold. First, pandemic restrictions meant that we could undertake no ethnographic work in phase 2, and our data collection more generally was affected by the unprecedented pressures on NHS staff . This also raises potential sample biases toward more technically literate participants , as well as those individuals with the time available to speak with us. We sought to mitigate these issues by offering phone as well as video interviews and adapting interview schedules to meet individual circumstances. Second, our positive and now longstanding working relationship with national- and regional-level stakeholders may have led us to view their change efforts in a positive light, though in other large-scale evaluations we have had equally positive relations with stakeholders but produced less positive reports . Third, Scotland’s story of scaling up video consultations resonates with what we know of other countries that had a relatively advanced infrastructure for telehealth—for example, Australia, where a small (and possibly skewed) survey found that up to 60% of health professional respondents had consulted by video during the pandemic, aided by a slackening of regulatory restrictions and more flexible reimbursement . In NorwBasu et al  have souIn the language of system innovation, the pandemic was what Van de Ven  would caopportunity for accelerated innovation and removal of barriers to experimentation; disruption to organizational and occupational practices, generating new dependencies and risks; and exposure of vulnerabilities in both people and infrastructures that have previously gone unnoticed, such as physical work spaces, IT networks, and key workers [Gkeredakis et al  apply 3  workers . Our finScotland’s national-level groundwork before the pandemic allowed many services to transform, at pace and scale, to a video-first mode of operating. Key contributors included the “burning platform” of the pandemic, national strategic vision, a well-resourced quality improvement model based around communities of practice and system learning, dependable technology, and multiple opportunities for staff to try out the video option.We anticipate that sustaining video as the new normal will depend on multiple issues such as digital infrastructure, human and financial resources (distributed fairly across the system), training , workforce (including extent to which video can help compensate for staff shortages), data security (including overcoming the tendency for regulations to be overly restrictive), and research into remote clinical examinations ,69.Evidence that remote care contributes significantly to greener health services is currently limited , but weScotland provides an important national case study from which other countries may learn. We invite others to apply the PERCS framework to their own case studies and propose refinements to it.