NIHR DC Discover

NIHR Signal Outpatient video consultations are feasible but challenging for the NHS

Published on 24 July 2018

doi: 10.3310/signal-000628

Video consultations may be a useful substitute for face-to-face consultations for some hospital outpatient appointments. This NIHR funded study provided insights into the conditions which made them better. When these practical and clinical conditions are met, video consultations can be safe and effective and are liked by staff and patients. But there are challenges in embedding new technology in routine practice, and these challenges may have been under-estimated.

This high-quality implementation study covered the benefits and challenges in the consultation, for organisations and policy-makers. Ad hoc Skype appointments seemed valuable to help people manage their diabetes. In addition, video appointments avoided the need to travel for people recovering from pancreatic cancer surgery. However, only a minority of out-patient appointments were thought clinically appropriate or practical to be conducted via video.

The research highlights the challenges of initiating a complex change at a system level.  This includes the need to think about integrating digital technology with care processes, protecting data, ensuring clinician buy-in, and avoiding unwanted knock-on effects.  The study provides useful pointers for others, including the need for phased introduction of new systems with input from staff and patients and close working with technical support teams.

These insights will be valuable for those planning to introduce video consultations and especially those wanting to extend the reach or maintain enthusiasm for the change.

Share your views on the research.

Why was this study needed?

There is increasing interest in using new technology to improve patients’ choice and experience in healthcare. A Cochrane review of telemedicine interventions, including 55 studies of remote monitoring and 38 studies of video conferencing, found similar health outcomes to usual care. Quality of life improved for those using telemedicine, but the effect on hospital admissions was uncertain. It was unclear whether video conferencing is suitable in all services or for all patients.

Despite the drive to increase use of digital technology in the NHS, outlined in the 2016 Government report Making IT work, there has been some clinician and organisational resistance to change. This study aimed to assess the feasibility of implementing video conferencing in a real-world NHS hospital setting and to learn lessons for others who wish to adopt the approach.

What did this study do?

This mixed-methods study evaluated using video consultations in a large NHS trust in London from an individual consultation, organisational and policy perspective. Video conferencing was made available in three services: diabetes, antenatal diabetes and in follow-up after cancer surgery.

At the consultation level, 30 video consultations and 17 face-to-face consultations were observed to establish the interactions and communication strategies used, and the effect of technology on the consultation length and interactions between clinician and patient.

At the trust level, the organisational, technical and other support systems for introducing and maintaining the services were evaluated through observing 300 consultations, and 24 healthcare staff interviews.

To address policy and legal barriers, 36 informal talks and 12 formal interviews were conducted with stakeholders from across government.

The study used valid qualitative methods to evaluate the system at multiple levels. It looked in depth at the reality of implementing video outpatient consultations in services which are both dynamic and unpredictable. The theoretical basis, sampling approach and qualitative data collection are well described.

What did it find?

  • By the end of this study, between 2 and 22% of consultations were being undertaken remotely by participating clinicians.
  • Video consultations worked well for people recovering from liver or pancreatic cancer operations as it avoided the need for them to travel. The proportion of video appointments rose from 7 to 20% during the study period.
  • Ad hoc Skype appointments were thought to be successful in a service for adults and young adults with diabetes. Formal outcomes were not available. Only one clinician tried the approach for 2% of her antenatal diabetes clinic, but it was unsuccessful because of the multi-disciplinary nature of the busy clinic.
  • There were organisational challenges, and implementation took longer than expected, was more complex and included real or perceived issues with information governance. Collaboration with the information technology department was essential for system set-up, technical troubleshooting, on-going support, and implementing protocols to comply with privacy and data protection regulations.
  • Video consultations were welcomed by some clinicians but not others. New work was created for immediate staff and the wider organisation including generating data, enabling access to the data, facilitating patients’ access, and tracking patients’ care.
  • Though policy makers were supportive of increased use of technology and believed it would lead to efficiency savings, there were limited resources for piloting and training. Given the complex and bureaucratic nature of the NHS, the current model of one-off purchases means digital service providers are reluctant to get involved. A final barrier to widespread adoption of video consultations was how trusts would be paid for providing this service.

What does current guidance say on this issue?

No relevant guidance is currently available, though there is increasing use of video for general practice consultations in the NHS.

What are the implications?

This study suggests that when certain conditions are met, video consultations can provide safe and effective alternatives to hospital outpatient appointments. However, there are challenges for organisations and individuals, and this is unlikely to be a quick fix or suitable for all patients and clinicians.

As seen from the variable adoption in different departments within the same Trust, not all services will necessarily encounter the same benefits or challenges when introducing video consultations. The pragmatic approach resulted in process and methods documents, available in supplementary appendices, which will be valuable resources for other NHS Trusts in developing further telemedicine services.

Some practical pointers emerged from this study. This included the need for slow and incremental introduction, working closely with clinical teams to align with existing practice. The authors also emphasised the need to adapt flexibly to the needs of patients and to clarify ways of working with technical support teams. Although this was a study from a single NHS organisation with limited patient sample, the study was designed to generate deep insights from careful observation and analysis at different levels which could be useful to others.

This study did not look for evidence of health effects, quality of life or costs of video consultations compared with face-to-face consultations. There is an assumption that this will lead to cost savings but this has not been tested. There is also the issue that an estimated 9% of the population have never used the internet and these people are more likely to be elderly, poor and sick. The effect of these interventions on inequalities in access to care should be part of future evaluations.

Citation and Funding

Greenhalgh T, Shaw S, Wherton J, et al. Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study. J Med Internet Res. 2018;20(4):e150. 

This study was funded by NIHR Health Services and Delivery Research programme HS&D-13/59/26. Two authors were also part-funded by the NIHR Biomedical Research Centre, Oxford, grant BRC-1215-20008.

Bibliography

Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;(9):CD002098.

National Advisory Group on Health Information Technology in England. Making IT work: harnessing the power of health information technology to improve care in England report of the National Advisory Group on Health Information Technology in England. London: Department of Health and Social Care; 2016.

NHS England. GP online consultations systems fund. Leeds: NHS England; 2018.

Why was this study needed?

There is increasing interest in using new technology to improve patients’ choice and experience in healthcare. A Cochrane review of telemedicine interventions, including 55 studies of remote monitoring and 38 studies of video conferencing, found similar health outcomes to usual care. Quality of life improved for those using telemedicine, but the effect on hospital admissions was uncertain. It was unclear whether video conferencing is suitable in all services or for all patients.

Despite the drive to increase use of digital technology in the NHS, outlined in the 2016 Government report Making IT work, there has been some clinician and organisational resistance to change. This study aimed to assess the feasibility of implementing video conferencing in a real-world NHS hospital setting and to learn lessons for others who wish to adopt the approach.

What did this study do?

This mixed-methods study evaluated using video consultations in a large NHS trust in London from an individual consultation, organisational and policy perspective. Video conferencing was made available in three services: diabetes, antenatal diabetes and in follow-up after cancer surgery.

At the consultation level, 30 video consultations and 17 face-to-face consultations were observed to establish the interactions and communication strategies used, and the effect of technology on the consultation length and interactions between clinician and patient.

At the trust level, the organisational, technical and other support systems for introducing and maintaining the services were evaluated through observing 300 consultations, and 24 healthcare staff interviews.

To address policy and legal barriers, 36 informal talks and 12 formal interviews were conducted with stakeholders from across government.

The study used valid qualitative methods to evaluate the system at multiple levels. It looked in depth at the reality of implementing video outpatient consultations in services which are both dynamic and unpredictable. The theoretical basis, sampling approach and qualitative data collection are well described.

What did it find?

  • By the end of this study, between 2 and 22% of consultations were being undertaken remotely by participating clinicians.
  • Video consultations worked well for people recovering from liver or pancreatic cancer operations as it avoided the need for them to travel. The proportion of video appointments rose from 7 to 20% during the study period.
  • Ad hoc Skype appointments were thought to be successful in a service for adults and young adults with diabetes. Formal outcomes were not available. Only one clinician tried the approach for 2% of her antenatal diabetes clinic, but it was unsuccessful because of the multi-disciplinary nature of the busy clinic.
  • There were organisational challenges, and implementation took longer than expected, was more complex and included real or perceived issues with information governance. Collaboration with the information technology department was essential for system set-up, technical troubleshooting, on-going support, and implementing protocols to comply with privacy and data protection regulations.
  • Video consultations were welcomed by some clinicians but not others. New work was created for immediate staff and the wider organisation including generating data, enabling access to the data, facilitating patients’ access, and tracking patients’ care.
  • Though policy makers were supportive of increased use of technology and believed it would lead to efficiency savings, there were limited resources for piloting and training. Given the complex and bureaucratic nature of the NHS, the current model of one-off purchases means digital service providers are reluctant to get involved. A final barrier to widespread adoption of video consultations was how trusts would be paid for providing this service.

What does current guidance say on this issue?

No relevant guidance is currently available, though there is increasing use of video for general practice consultations in the NHS.

What are the implications?

This study suggests that when certain conditions are met, video consultations can provide safe and effective alternatives to hospital outpatient appointments. However, there are challenges for organisations and individuals, and this is unlikely to be a quick fix or suitable for all patients and clinicians.

As seen from the variable adoption in different departments within the same Trust, not all services will necessarily encounter the same benefits or challenges when introducing video consultations. The pragmatic approach resulted in process and methods documents, available in supplementary appendices, which will be valuable resources for other NHS Trusts in developing further telemedicine services.

Some practical pointers emerged from this study. This included the need for slow and incremental introduction, working closely with clinical teams to align with existing practice. The authors also emphasised the need to adapt flexibly to the needs of patients and to clarify ways of working with technical support teams. Although this was a study from a single NHS organisation with limited patient sample, the study was designed to generate deep insights from careful observation and analysis at different levels which could be useful to others.

This study did not look for evidence of health effects, quality of life or costs of video consultations compared with face-to-face consultations. There is an assumption that this will lead to cost savings but this has not been tested. There is also the issue that an estimated 9% of the population have never used the internet and these people are more likely to be elderly, poor and sick. The effect of these interventions on inequalities in access to care should be part of future evaluations.

Citation and Funding

Greenhalgh T, Shaw S, Wherton J, et al. Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study. J Med Internet Res. 2018;20(4):e150. 

This study was funded by NIHR Health Services and Delivery Research programme HS&D-13/59/26. Two authors were also part-funded by the NIHR Biomedical Research Centre, Oxford, grant BRC-1215-20008.

Bibliography

Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;(9):CD002098.

National Advisory Group on Health Information Technology in England. Making IT work: harnessing the power of health information technology to improve care in England report of the National Advisory Group on Health Information Technology in England. London: Department of Health and Social Care; 2016.

NHS England. GP online consultations systems fund. Leeds: NHS England; 2018.

Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Published on 17 April 2018

T Greenhalgh, S Shaw, J Wherton,  S Vijayaraghavan, J Morris, S Bhattacharya, P Hanson, D Campbell-Richards, S Ramoutar, A Collard,  I Hodkinson

Journal of Medical Internet Research , 2018

Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. Objective: The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model. Methods: A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). Results: When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Conclusions: Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity

Expert commentary

How many of us have sat in the serried ranks of outpatient attendees worrying about the car parking costs or our capacity to get to our next appointment on time?

Video outpatient consultations allow patients to speak to their clinician from home; a particular bonus to patients for who travel is difficult and could be more cost-effective. 

But introducing new technology is no quick fix. It requires us to transform the work, the people who do it, and their relationships with one another and with patients. This study provides valuable insight into how to do exactly that.

Candace Imison, Director of Policy, Nuffield Trust