Video consultations for covid-19
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m998 (Published 12 March 2020) Cite this as: BMJ 2020;368:m998Read our latest coverage of the coronavirus outbreak
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Dear Editor,
We read with great interest the editorial by Greenhalgh et al. (BMJ 2020;368:m998) regarding the potential use of video consultation as a new model of care in response to the ongoing covid-19 pandemic. Of the two questions the authors pose, we would like to comment on the second: specifically, focusing on one of the challenges of scaling up this model at speed.
Prior to covid-19, we (Danish Society for Patient Safety) have been particularly interested in the role of telemedicine (of which video consultation is an example) in Danish healthcare. This is because, Denmark has been promoted as one of the world’s most digitalized countries (1) and for the last 15 years the government has worked on joint public sector digital strategies,(2) one of which is the deployment of digital health solutions such as telemedicine, to ‘provide freedom and empower individuals’.(3) From this perspective, telemedicine is understood as ‘the delivery of health care services using electronic communications and information technologies when participants are at different locations’.(4)
Even before the current covid-19 pandemic, telemedicine was seen as a popular solution to meet some of demographic and economic challenges of 21st century healthcare provision; therefore, implementation continued at pace. As a result of the current need to reduce the spread of covid-19, there is obviously increasing interest and demand for the adoption of telemedicine across the healthcare system to support the safe provision of healthcare. As such, it seems appropriate for an organisation such as ours, which is devoted to patient safety and quality improvement, to ask a simple question: What learning has occurred from reviewing the data relating to the use of telemedicine – in particular, patient safety incidents.
In 2019, we made an initial field analysis to answer this question. This process revealed data indicating a variety of risks and challenges for patients, professionals and the related authorities. This subsequently inspired us to map telemedicine patient safety related incidents in Denmark. Whilst we acknowledge, that the reporting of patient safety incidents does not necessarily provide the whole picture of the risk and harm associated with telemedicine, we believe it can contribute to learning about clinical sociotechnical interactions to develop safer systems and improve workflows.
Like a number of other countries, Denmark has a national incident reporting and learning system - Danish Patient Safety Database (DPSD) which enables patient safety incidents to be reported by healthcare providers. A recent modification to the system means patients and their families can now also report incidents.(5) A ‘patient safety incident’ is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient.(6) Once an event is reported to DPSD, it is automatically analysed locally for learning. At national level, the Danish Patient Safety Authority collects aggregated anonymized data from DPSD for learning and quality improvement. Each year, areas of interest are identified for deeper analysis at a national level. During 2018 almost 200,000 reports of patient safety incidents were administered. These range from ‘non-significant medicotechnical errors’ to ‘serious harm to a patient’. For each incident, the DPSD contains data fields such as ‘date of incident’, ‘location’, ‘category’ ‘type of incident’ e.g. medication error, and a free-text description of the incident.
Unfortunately, our attempt to collect data regarding telemedicine related patient safety incidents revealed only that the current configuration of DPSD does not provide a standardized way to report, collect, nor analyze data regarding telemedicine. There is simply no category for incidents when the health care is delivered digitally.
We subsequently tried to collect data from the Danish Medicines Agency (DMA) regarding events including medical devices used in telemedicine. By law, any medical device malfunction, failure or deficiency should be notified to the DMA by healthcare professionals and manufacturers. All reports are subsequently reviewed to determine if the manufacturer should make changes to the device, update the instructions for use or if the device should be removed from the market.(7) The current reporting system at DMA has similar limitations to DPSD. As such, it was not possible to extract patient safety incident data regarding medical devices used in telemedicine.
This can only lead us to believe that there is currently a gap between the current implementation of telemedicine, and the related modifications to the reporting systems developed to support potential for learning and quality improvement.
Information relevant to all stakeholders is falling through that gap. As a consequence, patients may be exposed to unnecessary harm, health care workers may inflict and be held responsible for unnecessary harm, and the authorities are unable to recognise potential trends in harm across the system.
The actions necessary to close this gap, and therefore reduce these potential harms, needn’t be overwhelming; new categories and reporting processes need to be adapted within the current system. The recent change to the system to allow patients and families to report incidents is an example of how modifications can be made.
As noted in the editorial: “…given the many clinical, technical, organisational, and policy questions raised by this promising service model and the natural experiment we are probably about to witness (due to covid-19), we strongly recommend a research call to ensure that we maximise the lessons learnt”.
Our recommendation is supplementary to this. Alongside the testing and implementation of any new technology, there needs to be an equivalent system of identifying, recording and learning from incidents involving that new technology. However, this is not where we find ourselves with telemedicine. If Denmark, or any other country, wants to succeed in the rapid utilization of telemedicine to support care provision during the current pandemic, or indeed as an international leader in digitalization, it will also need to be a world leader in systems to support reporting and learning.
1 European Commission website
The Digital Economy and Society Index (DESI)
https://ec.europa.eu/digital-single-market/en/desi
Date accessed: January 30, 2020
2 Danish Agency for Digitisation
Digital Strategy 2016-2020
https://en.digst.dk/policy-and-strategy/digital-strategy/
Date accessed: January 30, 2020
3 Danish Agency for Digitisation
National dissemination of telemedicine for patients with COPD by the end of 2019
https://en.digst.dk/policy-and-strategy/digital-welfare/telemedicine/
Date accessed: January 30, 2020
4 Danish National Health Data Authority
Healthcare conceptual framework
https://sundhedsdatastyrelsen.dk/nbs
Date accessed: January 30, 2020
5 Danish Patient Safety Authority
Patient safety incidents
https://stps.dk/da/laering/utilsigtede-haendelser/
Date accessed: January 30, 2020
6 WHO
Patient Safety
https://www.who.int/news-room/fact-sheets/detail/patient-safety
Date accessed: January 30, 2020
7 Danish Medicines Agency
Reporting of incidents and accidents with medical devices
https://laegemiddelstyrelsen.dk/en/devices/incident-reporting/
Date accessed: January 30, 2020
Competing interests: No competing interests
Dear Editor,
The authors have highlighted the potential use of video consultations for COVID-19 and outlined some of the system level challenges for implementation and scale up.
Despite the limited evidence, video consultations are widely used in resource-limited settings with robust telecommunication networks and a large number citizens use smart phones.
For example in India, there are several health start-ups offering video consultations, primarily as a triage tool providing medical advice and guidance on referral for further management. Majority of these video consultations and the referrals are external to the public health delivery systems. In India, nearly 70% of the healthcare delivery is by the private sector(1). The testing for COVID-19 is currently only available at designated government laboratories. In a fragmented health delivery ecosystem, video consultations could be the first line of contact between a suspected case with COVID-19 and the health-systems. The video consultation platforms could be mandated to trigger notifications on potential cases that need further evaluation and confirmatory testing for COVID-19. This would help strengthen the national disease surveillance network.
Moreover, as healthcare delivery establishments are likely to be overwhelmed with a large number of seriously ill COVID-19 patients in the forthcoming days, the video consultation platforms would serve a complimentary role in serving as an extension of the health delivery establishments. In addition, embedding machine learning algorithms into the video consultation platform could facilitate automation of the triage particularly for responding queries and help triage those at risk from those not at risk based on a symptom checklist and interactive voice interface that utilizes natural language processing capabilities (2). A potential model of remote home monitoring incorporating video consultations and remote virtual presence for chronic conditions such as end stage kidney disease have been described(3). COVID-19 offers an unprecedented opportunity to augment the health systems capacity leveraging these digital health tools.
References:
1. National Family Health Survey (NFHS-4), 2015-16: India.
2. Kuziemsky C, Maeder AJ, John O, Gogia SB, Basu A, Meher S, Ito M. Role of artificial intelligence within the telehealth domain. Yearbook of medical informatics. 2019 Aug;28(01):035-40.
3. John O, Jha V. Remote Patient Management in Peritoneal Dialysis: An Answer to an Unmet Clinical Need. InRemote Patient Management in Peritoneal Dialysis 2019 (Vol. 197, pp. 99-112). Karger Publishers.
Competing interests: The Author is Secretary of Asia Pacific Association for Medical Informatics and leads strategic engagement for the Digital Health India Association - a non profit agency that engages with Ministries of Health for progressing the digital health agenda towards SDGs.
Dear Editor
While Greenhalgh et al are right that the current Covid-19 crisis is prompting GPs to look at ways to avoid face-to-face contact they are wrong to focus on the use of Video consultations. There is a big danger in promoting cool technology when simpler alternatives are more effective.
Many GPs are already using online services for remote consultations in their routine practice (COI, I provide analytics to askmyGP, alternative platforms are available). Whatever previous published studies (most of which are weak and underpowered) say about patients being satisfied with video, there is a large volume of evidence that suggests they rarely choose it when offered better alternatives.
For example, askmyGP has processed around 1.7 million requests to GP practices since late 2018. This service allows patients to send a secure message to their GP describing their problem which the GP can read immediately and respond to in a variety of ways (patients can also contact their practice by phone to make the request; only about 30% do). The patient is asked their preferred method for the GP response (a phone call, a secure message, a face-to-face appointment or a video call). The GP can triage the request and choose a response (including asking for further information). The GP can choose to use a different response medium than the one requested by the patient (many f-to-f requests are handled by messages and many messages result in a f-to-f appointment). The mix of requested and delivered methods should be of interest.
In the 8 weeks from 20 January 2020 to 12 March 2020 askmyGP processed around 390 thousand patient requests. Of these only about 118k requested a f-to-f appointment, 110k a message and 143k a phone call (some patients who telephone their practice are not asked how they want the practice to respond). Only 357 (not thousand, just three hundred and fifty seven in total) requested video. Also worth noting is the fact that about 12k requests and responses involved sending a photo attachment (that's more than 30 times more than those requesting a video).
Patient satisfaction with askmyGP is very high (all requests are offered to chance to provide feedback and about 3% do and about 70% of responses give a top FFT response).
Our conclusion is that when patients and GPs are offered a variety of effective ways to communicate or have a remote consultation including video, very few choose video. Given the variety of practice types and the number of patients covered, this is a very significant result compared to the small trials reported in the literature, many of which did not test whether video consultations were better than other online or telephone alternatives.
We do not think that this evidence supports the promotion of video as the primary "best response" to encouraging remote consultations as a response to Covid-19.
PS we are very happy to share the raw data behind this conclusion with anyone who wants to validate it or investigate it further and have already done so with the analytics team at a major health think tank.
Competing interests: I provide the analytics for online GP service askmyGP (company name GP Access)
Looking Beyond COVID-19: Can Telemedicine Help Reduce Health Inequity?
Dear Editor
We have read with interest the editorial by Greenhalgh et al. (BMJ 2020;368:m998) regarding the potential use of video consultation in response to the ongoing covid-19 pandemic.
Indeed, telemedicine, “the remote diagnosis and treatment of patients by means of telecommunications technology” [1], has been a useful tool in previous pandemics, including former coronavirus outbreaks such as SARS-CoV and MERS-CoV [2]. We would like to highlight here another potential role of telemedicine, i.e. fighting health inequality.
COVID-19 has highlighted the importance of an integrated global health strategy and has again exposed the challenges faced by over 400 million people who do not have access to essential health services [3]. Africa, on average, has one medical doctor per 3324 inhabitants and one nurse or midwife per 995 inhabitants. Europe, in comparison, has one doctor for every 293 inhabitants and one nurse or midwife per 123 inhabitants [4]. There are similar patterns in terms of life expectancy. In Europe, the average person lives to the age of 76-81, whereas in Africa, between 53-60. Life expectancy and the causes of health inequity are complex, and outside of the scope of this article, however, we propose that telemedicine has the potential to improve access to healthcare in low-and-middle-income countries (LMICs) and that it can help break down some of the potential barriers within healthcare systems.
The Virtual Doctor’s charity experience thus far has largely been in rural Zambia, where we have been working alongside the Ministry of Health for over 10 years. We use a bespoke telemedicine app to enable UK-based volunteer doctors to give remote telemedical advice to healthcare professionals in the field. We currently support 140 rural health centres in Zambia and 6 in neighbouring Malawi. These are run by clinical officers (COs), who will have completed a 3-years medical training program, before they are employed as the first point of contact for healthcare within a community. Our service is text-based, with the option to send images, rather than using video-calls. This is partly due to the environment within which our service has developed with intermittent data bandwidth for video calls in much of rural Zambia. It also means that UK volunteers can answer queries at a time that suits them working around their NHS commitments.
Within many LMICs, there is often considerable variation in terms of workforce distribution: the majority of larger healthcare facilities, and hence healthcare workers, are usually focused around larger cities, and patients in rural areas may have to travel hundreds of kilometres, often on foot, or at significant personal expense, to see a doctor. There are often associated indirect costs, such as loss of income and the need to find temporary accommodation. In combination, these factors may prevent patients from seeking appropriate treatment, which can lead to worsening health inequity. Telemedicine, and the ability to connect rural healthcare workers with speciality doctors, is one tool to help address this. Patients presenting to their local health centre can discuss their condition with a CO. If the CO needs further advice, they can send a referral virtually to get a remote opinion within 24 hours.
To date we have answered over 5000 cases, and 90% of the time the advice given has improved patients’ symptoms. It has prevented referral to hospital in 76% of cases and 94% of the time the advice given was judged educationally beneficial by the COs. The service is also helping to reduce professional isolation and to improve the resilience of healthcare workers who can often be posted to isolated rural clinics away from friends and family. There is growing recognition of the potential reciprocal benefits that working within global health can have to home institutions [5]. This has been confirmed by our own experiences, and the technology we have developed in sub-Saharan Africa will soon be used by GPs and care homes within the South-East of England.
We look forward to seeing how telemedicine develops, both within and between Countries, as we cautiously come out of lockdown.
The Authors are members of The Virtual Doctors Medical Team. The Virtual Doctors are a registered charity in the UK and Zambia, that provide remote telemedical advice to rural health centres across Zambia. To find out more, get involved or make a donation please visit: https://www.virtualdoctors.org/
References
1 – What is Telehealth? NEJM Catalyst Feb 2018 https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268
2 – Ohannessian R, Duong TA, Odone A Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill. 2020 Apr-Jun; 6(2): e18810 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7124951/
3 – WHO https://www.who.int/mediacentre/news/releases/2015/uhc-report/en/
4 – WHO World Health Statistics 2020 https://www.who.int/data/gho/whs-2020-visual-summary
5 – Carbone S, Wigle J, Akseer N, Barac R, Barwick M, Zlotkin S Perceived reciprocal value of health professionals’ participation in global child health-related work. Globalization and Health volume 2017;13:27 https://link.springer.com/article/10.1186/s12992-017-0250-8
Competing interests: No competing interests