The PERCS framework (Figure 1), whose development and rationale is explained in detail elsewhere,11 is an adaptation of a more generic framework for considering the complexities involved when introducing new technologies.13 PERCS consists of eight interdependent domains:
The reason for consulting covers the illness or condition and why the patient wishes to be seen (or why the clinician wishes to see them) now. It considers the urgency, rate of progression, whether the appointment is patient or clinician initiated, and what advice or treatment is being requested. The patient includes attitudes towards illness and remote consulting, which are influenced by their identity, values, personality traits, beliefs, health and digital literacy, and lived experience of illness or disability. The clinical relationship includes the level of mutual trust and positive regard (often though not always linked to duration of relationship) and how well the clinician and administrative team know the patient. The home and family includes how the material features, physical layout, symbolic spaces, and interpersonal dynamics of the home influence whether and how the patient consults remotely. People who are disadvantaged may have no home, or one that is small, crowded, lacking privacy, or not digitally connected. Family members may support — or block — the patient’s digital access. Technologies includes the functionality, technical performance, and ease of use of key technologies as well as their dependability and familiarity. It also covers the technology’s supply chain and its maintenance and repair. Staff embraces staff attitudes (grounded in professional norms and values including those relating to quality and safety of care), their digital literacy and confidence, vulnerability to infection, and levels of exhaustion. Aspects of staff members’ home environment may be relevant if working from home. The healthcare organisation includes innovativeness, readiness, and normalisation efforts. Innovative organisations tend to be large, well led, non-hierarchical, and with adequate slack (people and resources that can be channelled into new projects).14 Readiness for innovation requires both top- and middle-management support, absence of opponents, and assessment of innovation-system fit (for example, a business case). Normalisation includes supporting staff to make sense of a new technology in the context of their work; engaging them to participate; coordinating efforts to implement; and monitoring benefits and costs.15 The wider system includes the policy context (for example, technology-enabled care, planetary health, social and digital inequalities) and infrastructural elements such as broadband availability. It also includes opportunities for interorganisational influence and learning (early-adopting organisations pass on insights and resources to those coming on stream later).14
These domains interact and evolve dynamically over time. The PERCS framework also includes two side panels — digital maturity of the organisation16–19 and digital inclusion for the population it serves.20–25 The domains of the framework are underpinned by the principles of healthcare quality,26 clinical ethics,27 and the ethics of care more widely.28
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