Why telemedicine is here to stay
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3603 (Published 06 October 2020) Cite this as: BMJ 2020;371:m3603
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Dear Editor
We agree that telemedicine is here to stay in some form.
At the beginning of March the Welsh Government funded the National Video Consulting (VC) Service to start rolling out video consultations as an emergency response to COVID-19. The initial rollout was in primary care to enable GPs and other primary care staff to continue offering care to people at home or in isolation to prevent the spread of infection. It also enabled the workforce to work remotely where required and continue offering care to patients in a safe and secure manner using the online platform Attend Anywhere across all of Wales. Toolkits and resources were developed at a rapid pace to enable this. There were technical challenges and also clinical challenges, but within less than six weeks almost 90% of the GP practices in Wales were set up to use video consultations to offer care and support to the public of Wales.
The National VC Service program has been robustly evaluating the rollout of video consultations in wales over the last seven months, using a mixed methodology approach. More than 20,000 survey responses and 200 clinical interviews our findings are suggesting that video consultations are here to stay. Satisfaction rates among primary care clinicians are high, and for patients they are persistently high across all care sectors, with 93% of patients reporting to want to use VC again after COVID, often in view of them having saved significant time and travel. The ability to work from home during the peak of the pandemic has protected the workforce from infection and also made clinicians realise the potential it has in supporting work-life balance.
As recruitment is a chronic and long-standing challenge, perhaps this needs to be considered by primary care teams in considering making future job descriptions attractive. Hence let's learn lessons from this pandemic and move forward with the positives so that we can improve healthcare for our patients and also be able to recruit and retain a healthy workforce.
The National Video Consulting Service is an NHS programme implemented and evaluated by Technology Enabled Care, and funded by the Welsh Government: See more at: https://digitalhealth.wales/tec-cymru/vc-service
Competing interests: No competing interests
Dear Editor
Since the ease of lockdown, managing workload was a ‘huge’ worry, causing anxiety amongst our colleagues in primary care. At Hillview Surgery, we had to look at new ways of working in order to offer support and care for our patients. Also, we needed to ensure the team were satisfied with new ways of consultations.
We have always offered telephone triaging at our practice, in addition to traditional Face-to-Face consultations. During pandemic we introduced complete telephone triaging model to all clinicians, to ensure patient and staff safety - resulting increased telephone/video consultations with reduced Face-to-Face consultations. However, anticipation of high volume of telephone calls to reception staff at Hillview was daunting! During early months of lockdown all clinicians (nurses, Health Care Assistants, doctors and clinical pharmacists) were involved in taking calls to ease the pressure faced by administrative team. We soon realised, this was not feasible and definitely not sustainable. By necessity, we decided to explore other ways of communication. eConsult was our rescue which increased patient access.
Objective was to solve queries raised by the patients safely, effectively and efficiently - within 24 hours. We hoped to reduce increased pressure faced by receptionists when patients request telephone consultations. Clinicians being able to manage workload in a relaxed timely manner, avoiding feeling rushed with several phone calls allocated on appointment slots; being able to focus and prioritise urgent queries promptly.
Here are some examples of how our team benefitted from eConsult in managing our workload.
Hypertensive patients asked to send their home BP readings via eConsult, hence avoiding the need for 24 hr BP monitoring. Seven day home BP monitoring sheet with instructions on how to check BP using their own BP machine twice a day is sent to patients and the completed template returned to surgery via email, enabling us to monitor hypertensive patients. Majority of our patients either had or were happy to buy BP machines.
Receptionists encourage patients with skin problems (rashes/pigmentations/moles) to send photos via eConsult in the first instance. Photos saved in patient’s notes with consent help clinicians to compare any future changes - particularly useful with chronic healing ulcers, acne, chicken pox or shingles; in circumstances when clinician feels the need to see patient, can easily managed via video consultation or Face-to-Face as appropriate, without any delay.
Women needing repeat prescriptions of their contraceptive pill, patches, Sayana Press (depo-injection), HRT or advise on contraception are able to access nursing team without any delay. Despite Faculty recommendations on verbal consent for implant insertion/removal and coil insertion, opinion varies amongst the fitters. At Hillview, we have been traditionally getting written consent to such procedures. Following an extended telephone consultations with patients regarding such procedures, clinicians send consent form to patients electronically for review. Patient has the option of replying to the message or uploading signed consent form via email. For other procedures like ear syringing and minor surgery, similar approach could be taken for written consent - minimises Face-to-Face patient exposure, but also help reduce GP surgery carbon footprint.
Any issues related to repeat prescriptions or new medications prescribed by hospital specialists managed in a timely manner, by patients sending email to the surgery - directed to clinical pharmacists.
Historically, letters sent inviting asthma patients for nurse review was not successful as many stable patients DNAed their review. However, by sending asthma review questionnaires to patients via MJog was a success, as patients were happy to return completed questionnaire via eConsult - saves clinical and administrative time, and improves patient care. Stable mental health patients requesting repeat prescriptions completing PHQ-9 and GAD-7 questionnaires via eConsult is invaluable. The service being extended to diabetic and hypothyroid patients.
Nursing team are already planning to send our unique personalised “Holistic Care Record” (care planning of our patients with learning disability, dementia) to patients electronically, which when completed sent back to the surgery by patients/carers via eConsult, before saving in patient’s records.
Majority of administrative tasks including prescription requests, test results, sick note are handled appropriately, saving receptionists’ time taking calls. Administrative team extract useful clinical data such as smoking status, alcohol consumption and allergies reported and code into patient’s records. Patients needing to contact our referrals team send queries directly to administrative team. Patients needing supportive letters or private referrals contact clinicians with ease and dealt with in a timely manner.
Introduction of email access to patients at Hillview, have saved clinical time and allowed for either more patients to be treated in a day or for more complex patients to have longer Face-to-Face consultations. Additional information on eConsult increases efficiency of Face-to-Face and Telephone consultations. Patients like the idea of no queue when submitting the email. Every request is reviewed and most appropriate care given to each patient in a timely manner. If a patient does need a follow-up the clinician has already seen a full history so can begin treating immediately.
Advantage of this service is that it also give patients the option of access to self-help and advice. Self-help section on the platform contains pages on common illnesses, syndicated from the NHS Choices website - guide allow patients to check their own symptoms, gives guidance on how to self-help if appropriate, and advise on when and if they should seek appointment with a clinician; paramount importance in educating patients about their care while encouraging positive attitude/behaviour. This is welcoming news, as this enable patients who need urgent care, have no access to internet or unable to use email due to language barrier/vision impairment to access our surgery with much ease.
Feedback from patients and clinicians including monthly eConsult data are encouraging. I agree eConsult is not for everyone. However by increasing patient access to surgery via email enables those patients who opt to use this mode of communication more convenient; enables clinicians to manage daily workload in a much better controlled way.
eConsult has certainly revolutionised our ways of working at Hillview and here to stay in the foreseeable future.
Competing interests: No competing interests
Dear Editor
The move towards telemedical consultation in light of the COVID-19 pandemic is driving innovation in General Practice at pace, however omitted from consideration in this otherwise excellent piece is the impact digitalised consultation will have on the development of medical trainees. A placement in General Practice for a medical student prior to the current pandemic provided a unique opportunity to involve oneself in the care of a patient while receiving reactive in-person feedback from an experienced clinician. The opportunity to consider a case, perform an examination, and decide on appropriate investigation and management in real time, with a patient in the room and a supervising doctor ready at hand to offer advice and guidance is what makes General Practice placement a vital component of a medical degree.
Looking back on my experience as a medical student, often the presentations I encountered in General Practice which an experienced clinician would consider routine and manageable via a teleconsultation were the cases that developed my clinical judgement and examination skills the most. These cases are often the ones which allow a student to build their confidence as a clinician. I fear that with the move to teleconsultation, the in-person exposure for the medical student to these types of presentation will diminish.
Competing interests: No competing interests
Dear Editor
‘Tele‘ is from the Greek, meaning, ‘far off’, and a Clinician is ’a doctor having direct contact with patients’ (1).
The term, ’Telemedicine’ is therefore oxymoronic unless ‘medicine’ now refers solely to the distribution of drugs and not to the clinical activity of examining patients.
How does one detect hepatomegaly, feel for lymphadenopathy, do a PR, percuss the chest, elicit rebound tenderness, or assess the reflexes, using a screen or telephone encounter?
The doctor-patient relationship is more than a mechanical, data-gathering exercise, replaceable by computer algorithms and implantable bio-sensors (2).
Singh & Leder (3) explain that touch has the potential to communicate, soothe, and heal, and medicine is diminished if it avoids the exploration and utilisation of the power of touch. Increasingly, the direct doctor–patient contact often gives way to a reliance on technological devices that help diagnose, and later treat, the patient. It is not unusual for a doctor to stride into a hospital room and, rather than reach for the patient, reach instead for the chart with the latest lab results.
Yet, therapeutic touch is pivotal in certain areas of modern and traditional medicine, including physiotherapy, osteopathy, chiropractic, and acupressure. Can verbal skills replace the expert hands of a physiotherapist in relaxing tight muscles, or those of a chiropractor realigning a contorted spine? Can words alone replace the touch of a GP who reaches out to a distraught patient to demonstrate empathy and to recognise suffering? Touch can be used to bridge the emotional and physical gap between a physician and patient. It can directly express care, compassion, and comfort. It has the potential to play an important part in the healing process, reinforcing patient trust and concordance, along, perhaps, with the ‘placebo effect’, triggering the body's own capacity for self-healing.
Gadow (4) points out that, technology, on the other hand, has the potential to violate human dignity to the extent that its use reduces persons to the moral status of objects. The prevalence of technology in health care is an extension of the scientific paradigm, in which the body is reduced to an object devoid of subjectivity. The empathy paradigm, in contrast, is based upon the moral primacy of subjectivity. Empathic touch - as distinct from instrumental and philanthropic touch - establishes a clinical relation of intersubjectivity, affirming in patients the dignity and worth that morally distinguish persons from objects.
This has seemingly been written out of the script in the rush to technological, so-called ‘progress’.
Will empty waiting rooms be quite as appealing when medical personnel suddenly realise that they have willingly participated in their own redundancy?
(1) Oxford Dictionary of English, 2nd edition, 2003: Oxford University Press
(2) https://www.mintpressnews.com/darpa-tech-diagnose-covid-19-implantable-b...
(3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289810/
(4) https://link.springer.com/article/10.1007/BF00999900
Competing interests: No competing interests
Re: Why telemedicine is here to stay but who is driving
Dear Editor
Phone and telemedicine have some clear advantages especially for the simple quick single issues for the IT confident people
But
Does it save clinician time overall?
(I would say almost certainly not)
Are we in danger of stacking up problems by the initial online consult with suggestions that may not solve the problem? How many online or telephone consults should we allow before f2f and touch is needed for safety?
Is the huge reduction in cancer referrals since the change to online a temporary aspect not associated with the technology or are we missing the why I am here and by the way questions or just plain clinical hunch (a proven predicator) that might not be so obvious online?
There is a lot of money at stake, as well as the political push to change to this type of service, but should we be cautious before we cut back on bricks and mortar of primary care provision in house?
Competing interests: No competing interests