BMJ No 7069 Volume 313 Education and Debate Saturday 30 November 1996
Can telemedicine be used to improve communication between
primary and secondary care?
Robert Harrison, William Clayton, Paul Wallace
- Abstract
Objective- To test feasibility and acceptability of
teleconferencing routine outpatient consultations.
- Design- Exploratory trial of teleconferenced
outpatient referrals of general practitioners.
- Setting- An inner city teaching hospital and
surrounding general practices.
Subjects- Six general practices linked to hospital
outpatient clinics.
- Main outcome measures- Levels of participants'
satisfaction measured with self administered questionnaires.
- Results- 54 teleconsultations were performed in 10
different specialties. Few serious technical problems were encountered,
and high levels of satisfaction with the consultations were reported by
patients, hospital specialists, and general practitioners.
- Conclusions- Teleconferenced consultations for
routine outpatient referrals with joint participation of general
practitioner were feasible. These may have an important potential
benefit for improving communication between primary and secondary care.
- Introduction
Problems in communication between hospital specialists and general
practitioners are a well documented feature of the interface between
primary and secondary care, especially in inner city
areas.( 1) Written communications have been shown to
be of variable quality( 2) ( 3) and are
often of poor educational value.( 2) ( 4)
The need for improved communication between hospitals and community
care has been recognised by the NHS as a priority for its research and
development programme.( 4)
There are several ways in which communications between primary and
secondary care may be improved, such as the more effective use of
telephones, outreach clinics, and greater use of joint domiciliary
visits. There is evidence that some general practitioners and
specialists make extensive use of the telephone, but in general it is
not used a great deal and programmes to increase its use have not
proved successful.( 5) There has been a major
expansion in the use of outreach clinics, in which consultants see
patients in a general practice setting, but current evidence indicates
that these do little to improve interaction between general
practitioners and specialists.( 6) They are also
expensive in consultant time. Domiciliary visits are now uncommon apart
from in medicine of old age and psychiatry. They are also costly (in
1988 they cost an estimated £20 000 000 in consultants' fees
alone) and generally fail to bring hospital specialists and general
practitioners together in a joint
consultation.( 7) ( 8)
A study of joint orthopaedic consultations, in which specialists and
general practitioners reviewed patients together, found that joint
consultations of this kind could lead to substantial educational gains
for the participating doctors, together with improved patient welfare
and more efficient use of the health service.( 9)
The main problem with this type of consultation is the requirement for
the hospital specialist or general practitioner, or both, to leave
their usual place of work. Teleconferencing offers a solution to this
by using a video link to obviate the need for travel.
Although telemedicine has experienced a number of false
dawns,( 10) there are now converging economic,
technical, and political trends that make expansion of its role likely.
The cost of basic videoconferencing technology is falling. Standards
set by the telecommunications industry are achieving conformity, and,
with the advent of digital transmission, effective channels are
available through existing telephone and cable networks. In the NHS
investments in the national NHS-wide electronic network, the uniform
patient number, and electronic medical records show a commitment to
using effective electronic linkage.
To evaluate the potential benefits of joint teleconsulting we undertook
a feasibility study using a standard, commercially available
videoconferencing package and telecommunication links. An additional
aim of our study was to examine to what extent it might effectively be
used as an alternative to outpatient referral and to obtain an
indication of its acceptability to all the parties involved.
- Subjects and methods
After informal discussions and interviews, six general practices were
selected to have access to 10 hospital specialists based at the Royal
Free Hospital, London, for scheduled teleconsultations. The specialties
were dermatology; endocrinology; ear, nose, and throat;
gastroenterology; gynaecology; oncology; orthopaedics; paediatrics;
psychiatry; and urology. We used semi-structured interviews to
determine the expectations of potential participants and to identify
criteria for successful consultations.
The specialists and general practices were equipped with a standard
commercial videoconferencing equipment for desktop PCs (British Telecom
VC 8000). This consisted of Screencall software, a card to go inside
the computer, a telephone handset, and a small video camera that
could be mounted on the top or side of a computer monitor. A mobile
unit was developed for the consultants. This included a special
camera-screen interface to enable better eye to eye contact with the
patient. The equipment was linked through Integrated Service Digital
Networks (ISDN) lines to allow simultaneous live audio and video
transmissions with a basic overall
quality.
Access to the service was through a direct line to the research office,
from where the administrator arranged the appointments. There were no
formal criteria for the selection of cases during the feasibility
trial: general practitioners were free to refer as they wished to the
specialties in the study (if the participants were dissatisfied it was
always possible for the patient to attend the hospital). The joint
teleconsultations were achieved through arranging an appointment time
convenient for the patient, general practitioner, and specialists.
After each consultation, all three participants completed a self
administered questionnaire. Questions were designed to measure
satisfaction with the quality of the consultation and the technical and
administrative performance by means of five point, Lickert-type scales.
The perceived reason for the consultation and the outcome were also
requested. Consultants were asked to record whether they regarded the
referral as appropriate, also with a five point scale. A framework for
an economic appraisal was also developed.
- Results
A total of 54 teleconsultations were booked and conducted over a period
of five months. The research office was notified of one refusal. Five
of the six general practices with access to the system participated.
The practice that did not participate was atypical from in that it was
a fundholder outside the catchment area of the Royal Free Hospital. All
the general practitioners who tried the system had at least one
successful teleconsultation.
- TECHNICAL FEASIBILITY
Four of the early consultations were subject to serious technical
failure, such as loss of sound or vision, or both. The images were not
adequate for the dermatologist. Apart from those referred to
dermatology, the patients had conditions that could be dealt with on
the basis of their history, test results, and, occasionally, a visual
examination. This usually required patients to show the distribution of
their symptoms or the range of movement of joints. In one case the
endocrinologist asked a patient to drink a glass of water in order to
examine a goitre. The quality of the images were found to be
satisfactory for these purposes.
- PARTICIPANTS SATISFACTION
The self administered questionnaires were completed by 43 (80%) of the
patients, 43 (80%) of the general practitioners, and 48 (89%) of the
consultants.
| Table 1 Ç Views of general practitioners and specialists who participated in 54 teleconsultations |
|
No (%) of doctors who agreed or strongly agreed with statement |
| Statement |
General practitioners (n=43) |
Specialists (n=48) |
| Communication was adequate |
42 (98) |
41 (87) |
| Information I obtained was adequate |
40 (93)* |
43 (94) |
| Rapport with the patient was good |
39 (93)* |
42 (89) |
| I was satisfied with the patient's response |
40 (95) |
41 (87) |
| Quality of the sound was satisfactory |
35 (81) |
26 (54) |
| Quality of the vision was satisfactory |
34 (79) |
26 (54) |
| Overall quality of the telelink was good |
39 (91) |
32 (68) |
| Arrangements worked well |
40 (93) |
41 (85) |
| *Not all questions were answered in each completed questionnaire. |
Doctors' satisfaction- Table 1 shows the levels of
satisfaction reported by the general practitioners and consultants.
Both groups of doctors generally recorded positive responses for all of
the items used in the evaluation. The consultants were somewhat more
critical of the technical performance, rating both sound and vision
positively in only 54% of evaluated consultations. However, they
expressed higher levels of satisfaction with the level of communication
and information received. The consultants classified 44 (92%) of the
referrals as most certainly or certainly appropriate. No referral was
classified as inappropriate.
Patients' satisfaction was measured in both
general statements and through specific parameters such as rapport,
shyness, and confidentiality. The two overall measures were the
patient's general satisfaction rating and their willingness to
teleconsult again (tables 2 and
3).
| Table 2 Ç Views of 43 patients who participated in teleconsultations |
| Statement | No Responses to statement |
|
Positive
| Neutral
| Negative
|
| After using the television link this is how I would feel about using it again
| 36 (84)
| 7 (16)
| 0
|
| In general I felt my experience of using the television link was
| 41 (95)
| 0
| 2 (5)
|
| Table 3 Ç Views of 42 patients who participated in teleconsultations |
Statement | No (%) responses to statement* |
|
Agree |
Neither |
Disagree |
| I felt the consultant could understand my problem |
36 (86) |
2 (5) |
4 (10) |
| I was able to say all I wanted |
36 (86) |
1 (2) |
5 (12) |
| I was worried others might be listening |
3 (8) |
6 (15) |
31 (78) |
| I felt shy and nervous about speaking |
8 (21) |
3 (8) |
29 (73) |
| I could not say all I wanted |
8 (20) |
1 (3) |
32 (78) | | *Not all items were completed and some replies were ambiguous, so that total No of responses not always 42 |
- Discussion
As far as we are aware, this is the most comprehensive reported study
of participants' views of teleconsulting to date. Previously published
studies of teleconsulting have, except for one study, examined only the
patients' responses.( 11-13) Our study has shown
that the teleconferencing of outpatient referrals, with the joint
participation of the general practitioners and hospital specialists,
was feasible and acceptable to all parties involved. The satisfaction
ratings recorded by all three groups of participants were consistently
favourable and provide strong evidence that, for certain categories of
referrals, joint teleconferenced consultations may be an appropriate
alternative to routine outpatient visits.
- FEASIBILITY OF TELECONSULTATIONS
The use of teleconferencing did not pose substantial technical
problems. While the areas that received the least positive appraisal
were technical performance and administrative arrangements, it must be
appreciated that all the participants were novices with the technique.
It is likely that increased practice and training would result in
greater skill. Clear reasons were identified for the negative technical
scores, such as too poor an image. The dermatologist's dissatisfaction
with the quality of the images was in part due to the financial
constraint placed on the technical investment in the practices, the
level of skill of the users, and the limitations of current " off the
shelf" software.
Other negative scores were due to administrative problems such as
missing medical records. The relatively poorer ratings on technical
performance by consultants is probably because they placed greater
demands on the technology, which had to provide them with adequate
sound and vision. Also, the general practitioners and patients usually
used the equipment in " hands free" mode, which reduced the quality
of the sound received by the consultant.
While there was scope for technical improvement, the basic quality of
the audio-visual link did not seem to inhibit satisfactory
consultations, providing a link was successfully made. Moreover, the
collaboration needed to overcome any practical problems during the
consultation seemed to increase the rapport between the participants.
Most of the technical difficulties would be readily resolvable with
improved software and a relatively inexpensive upgrade in
telecommunications.
- DRAWBACKS OF TELECONSULTATIONS
The inability of consultants to perform a physical examination
may be perceived as a drawback for teleconsulting. In our study,
however, some physical examinations did occur. These were visual
examinations of patients, usually involving their demonstrating the
problem or site of complaint. In some cases an examination by proxy was
performed, with the general practitioner being guided by the
consultant. In one case the ear, nose, and throat surgeon requested an
appointment with the patient for direct visual inspection of their
nasopharynx. With an appropriate level of investment- for example, in
fibreoptic instruments- this could be achieved from the general
practitioner's surgery.( 14)
Concern has been expressed about legal liability and teleconsultations.
Essentially, there is no difference between a teleconsultation and a
conventional outpatient referral.( 15) The onus
is on the general practitioner and the consultant to make clear who
is taking responsibility. Contemporaneous written records are required
as for the usual type of referral.
Teleconsulting does create logistical problems in that all parties have
to be present at the same time. This was manageable in our small scale
trial, but it would undoubtedly cause greater difficulties if a service
was introduced on a larger scale. Preliminary experience indicates that
there may be a feasibility ceiling of two to three teleconsultations a
week for a general practitioner. This would, however, represent a large
proportion of suitable referrals, as teleconsulting would not be
appropriate for all referrals. This level of teleconsulting could be of
considerable educational value, and the possibility of teleconsulting
being made eligible for the post graduate educational allowance are
being explored.
Joint consultations may involve more general practitioner time.
Research indicates, however, that there are fewer return visits to the
general practitioner after a joint consult.( 9)
Our own study was too short to register any possible changes in
referral behaviour. For patients, the reliability of appointment times
is likely to be a considerable improvement on conventional
outpatient clinics.
It is encouraging that the teleconsultations in our study could be
accomplished effectively with relatively low level equipment based on
desktop PCs in the doctors' usual workplace. The expected development
of multimedia electronic record systems and the NHS-wide electronic
network make it likely that the quality of, and access to,
teleconsultations will improve.
- LIMITATIONS OF STUDY
While our preliminary study showed teleconsulting to be feasible
and acceptable, the viability of this particular form of telemedicine
is not yet proved and there are several factors which limit the
conclusions that can be drawn from the study. The sample of general
practitioners and hospital consultants is unlikely to be representative
of the profession as a whole. Selection bias was strongest among the
general practitioners, who were self selected enthusiasts. The initial
evaluation of technical innovation will almost always be with
enthusiasts, but this is likely to influence the doctors' satisfaction
rather than that of patients. The patients who took part were largely
unselected, with only one refusal to participate being reported by the
general practitioners.
A larger, more rigorous study will be needed to evaluate this use
of innovative technology. This will require a properly designed
randomised control trial of adequate size and incorporating appropriate
outcome measures. A pilot study of such a trial is currently in
progress.
| Key messages |
- Recent research shows that improved communication between doctors in primary and secondary health care in the form of joint consultations improves the quality of health care, is of educational value, and leads to a more economic use of health services
- Teleconferencing would allow doctors to achieve joint consultations through sound and video links without having to leave their usual workplace
- In our preliminary trial we used low cost, PC based, videoconferencing equipment to connect six general practices to 10 specialities in a hospital
- Few serious technical problems were encountered, and high levels of satisfaction were reported by the patients, hospital specialists, and general practitioners who participated in the consultations
- The feasibility of teleconsultations should now be tested in a full scale trial
|
We acknowledge the support and guidance of the steering
committee's members: Professor A Haines, Dr J Roberts, Ms D Holmes,
and Dr D Harris. In particular, we acknowledge the support and
encouragement of Mr P Garner, care project manager, BT Laboratories. We
also gratefully acknowledge the help of the Royal Free Hospital NHS
Trust and the following hospital specialists and general practitioners:
Dr O Epstein, Mr R Morgan, Dr P Bouloux, Mr N Goddard, Mr R Quiney,
Professor A MacLean, Professor B Taylor, Dr V van Someron, Dr D Flynn,
Dr P McLaren, Dr A Jones, Mr D Economides, Dr H Chester, Dr J Sandford,
Dr K Hoffman, Dr K Fraser, Dr A Parker, Dr P Wiseman, Dr S Corcoran, Dr
C Mitchell, and Dr A Selwyn.
Funding: NHS Research and Development Programme with additional
support from Camden and Islington Health Authority and BT Laboratories.
Conflict of interest: None.
Department of Primary Care and Population Sciences,
Royal Free Hospital,
University College Schools of Medicine,
London NW3 2PF
Robert Harrison,
research fellow
telemedicine
William Clayton,
project
coordinator
Paul Wallace,
professor of primary
care
Correspondence to:Mr Harrison (email virtual@rfhsm.ac.uk).
- REFERENCES
1 Roland M. Communication between GPs and specialists. In:
Roland M, Coulter A, eds. Hospital referrals . Oxford: Oxford
University Press, 1992: 108-22.
2 Advisory Group on Health Technology Assessment.
Assessing the effects of health technologies: principles practice
proposals . London: Department of Health, 1996.
3 Coulter A. Envoi. In: Hopkins A, Wallace P, eds.
Referrals to medical outpatients. London: RCP
publications, 1992: 97-103.
4 Department of Health. Research for health: a research
and development strategy for the NHS . London: DoH, 1991.
5 Roland M, Bewley B. Boneline: evaluation of an initiative to
improve communication between specialists and general practitioners.
J Public Health Med 1992;14 :307-9.
6 Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in
general practice. BMJ 1994;308 :1083-6.
7 Littlejohns PC. Domiciliary consultation- who benefits?
J R Coll Gen Pract 1986;36 :313-5.
8 Fry J, Sandler G. Domiciliary consultations: some facts and
questions. BMJ 1988;297 :337-8.
9 Vierhout WPM, Knottnerus JA, van Ooij A, Crebolder HFJM, Pop
P, Wesselingh-Megens AMK, et al . Effectiveness of joint
consultation sessions of general practitioners and orthopaedic surgeons
for locomotor-system disorders. Lancet
1995;346 :990-4.
10 McLaren P, Ball CJ. Telemedicine: lessons remain unheeded.
BMJ 1995;310 :1390-1.
11 Hubble JP. Interactive video-conferencing and Parkinson's
disease. Kans Med 1992;93 :1212-4.
12 Allen A, Hayes J. Patient satisfaction with tele-oncology.
Telemed J 1995;1 :41-6.
13 Dwyer TF. Telepsychiatry: psychiatric consultations by
interactive television. Am J Psychiatry
1973;130 :865-9.
14 Rinde E, Nordrum I, Nymo BJ. Telemedicine in rural Norway.
World Health Forum 1993;14 :71-7.
15 Brahams D. Legal and ethical issues. In: Thick M, ed.
Telemedicine risks and opportunities . London: Royal Society
of Medicine, 1996: 54-61.
(Accepted 7 November 1996)
Full text on BioMedNet
Current contents | Classified ads | Archive and search | Local editions | Advice to authors
Reprints | Subscriptions | Feedback | Home
|