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Telemedicine or Face-to-Face Consultations?

Picture of girl sitting on her bed using her laptop.

During the Covid-19 epidemic many GP practices have been offering patients video or telephone consultations. The Health Secretary, Matt Hancock, is so delighted by this development that he wants GP practices to make telemedicine their primary means of serving patients. We have been researching telemedicine for over 20 years and the evidence is very clear: whilst telemedicine can serve many very useful purposes it cannot be a replacement for face-to-face consultations.

There is often a euphoria associated with a new digital technology that assumes it will replace existing ways in which people get things done. But what often happens in practice is that the new technology becomes a complement to existing practices rather than replacing them. The demise of paper has, for example, been forecast for over 30 years but it is a very useful and flexible technology and is still flourishing alongside electronic publishing. We have every reason to believe that the same will happen to telemedicine: it will find its own niche alongside face-to-face consultations but it will not replace them. The task now is to work out when it can be most usefully and safely deployed and when face-to-face consultations are essential. Then we need to promulgate this knowledge as advice to help all medical practitioners.

Some distinctions are obvious. There are many diagnostic procedures that depend upon the doctor making a physical examination of the patient and face-to-face consultations will remain essential for these purposes. And there are many circumstances where the patient needs the doctor’s best ‘bedside manner’ to support them through anxious times. Who can imagine giving a patient bad news via Zoom!

What of the value of telemedicine? We have found examples where it adds substantially to what the medical profession can offer. One example is offering the patient support whilst they engage in home medical care: for example, having a diabetic nurse available via a telemed link whilst a new diabetic patient gives themselves an insulin injection. Recently we did some research with home dialysis patients who were supported through this complex process by a telemed link to dialysis specialists in the local hospital. We have also been working on the value of telemed links for people with learning disabilities for whom a visit to a GP practice can be a traumatic event: far better for them to ‘see’ the doctor in the familiar setting of their own home.

But some more general lessons have emerged from an evaluation conducted by Ipsos-Mori of the Babylon ‘GP at Hand’ service.

https://www.hammersmithfulhamccg.nhs.uk/media/156123/Evaluation-of-Babylon-GP-at-Hand-Final-Report.pdf 

Patients who join ‘GP at Hand’ leave their existing GP practice and opt for a telemedicine-first service. The evaluation found that the service was popular with young, fairly healthy patients who were busy with work and could not easily get to a GP surgery during the day. It was not so popular with the elderly or those with complex needs. And when the young patients found they had a more complex condition and they wanted a face-to-face consultation they often became dissatisfied with ‘GP at Hand’ and reverted to their original practice.

On this basis telemedicine has an important role to play in routine consultations but there needs to be an easy way to switch to face-to-face consultations if conditions become complex and patients become anxious.

Health care for all: effective, community supported, healthcare with innovative use of telemedicine technology

Abstract:

Almost half of the world’s total population reside in rural and remote areas and a large number of these people remain deprived of most basic facilities like healthcare and education. It is deemed impossible for government with scarce resources in developing countries to open and run a health facility in every remote community using conventional means. One increasingly popular unconventional mean is the use of existing technology to improve exchange of medical information for the purpose of improving health of underprivileged communities. Telemedicine implies the use of information and communication technology to provide health care remotely from a distance. With the induction of telemedicine, patients who live in rural and remote areas can have increased access to medical services. In many developing countries, use of telemedicine however has been limited mainly to teleconferencing between primary and secondary/tertiary care facilities for diagnosis and management of patients. This system still requires patients from remote communities to travel, often long and arduous journeys to the centre where telecom and medical facilities are available. Health Care 4 All International, a not for profit registered charity is providing primary care to patients by taking telemedicine into their homes in remote communities, thus obviating the need and hardships of travel for patient.

Journal of Pharmaceutical Policy and Practice Link

Tariq Kazim ShahEmail author, Tasneem Tariq, Roger Phillips, Steve Davison, Adam Hoare, Syed Shahzad Hasan and Zaheer-Ud-Din Babar, Journal of Pharmaceutical Policy and Practice201811:3

https://doi.org/10.1186/s40545-018-0130-5

Patient Safety in Community Care: e-health systems and the Care of the Elderly at Home

Handbook of Research on Patient Safety and Quality Care through Health Informatics

This chapter reviews a number of technologies used for remote care: telecare, telehealth, telemedicine, electronic patient record systems, and technologies to support mobile working.

Abstract:

The increasing number of elderly people in need of health and social care is putting pressure on current services to develop better ways of providing integrated care in the community. It is a widely held belief that e-health technologies have great potential in enabling and achieving this goal. This chapter reviews a number of technologies used for this purpose: telecare, telehealth, telemedicine, electronic patient record systems, and technologies to support mobile working. In each case, technocentric-design approaches have led to problematic implementations and failures to achieve adoption into the routine of delivering healthcare. An examination of attempts to implement major changes in the service delivery of integrated care shows that e-health technologies can be successfully implemented when they are seen as an intrinsic part of the creation of a complete system. However, the design process required for successful delivery of these services is challenging; it requires sustained and integrated development work by clinical staff and technologists coordinating their work on process changes, organisational developments, and technology implementations.

Patient Safety in Community Care: e-health systems and the Care of the Elderly at Home Ken Eason

Link to IGI Global

Eason K. D. and Waterson P.E Patient Safety in Community Care: e-health systems and the care of the elderly at home In Michel V., Gulliver S., Rosenorn-Lang D. and Currie W. (eds) Patient Safety and Quality Dimensions of Health Informatics. IGI Global 198-213

A Socio-Technical Approach to Evidence Generation in the Use of Video Conferencing in Care Delivery

Evidence of outcomes across multiple uses of video conferencing in health and social care delivery – a socio-technical perspective

Video conferencing in care delivery telemedicine socio-technical v-connect Adam Hoare

Use of Video Connection Platform in Multiple Verticals of Care Delivery

Abstract:
Care and support services need to respond to the rapidly changing demands of the population and available resources. The authors will present evidence that video conferencing can underpin many of the aspirations for future care delivery. However, if the necessary scale and pace are to be achieved a new model for evidence generation needs to be found. Using the experience of deploying video across health and social care a new model of evidence generation will be proposed based on a socio-technical approach where complexity and human capabilities are features of the intervention. A practice-based approach utilising action research will be used. The model will focus on four dimensions that are key to the success of an intervention using video: Practice, Outcomes, Technology and Evidence. Addressing the interactions between these four dimensions promotes a system that can evolve services that, in cooperation with the video technology platform, can satisfy changing care demands

The effects of current economic and demographic pressures on care and support systems are well documented. The need to do more with less is an established requirement of new models of care. However, there are significant barriers to the innovation of new ways of working in care delivery. Some of these barriers will be described through the experiences of one of the authors (AH) in deploying video conferencing to support people in their own homes or in a care environment.

The current use of video in care delivery is predominantly clinician-to-clinician communication between care organisations. Established examples are stroke or cancer networks. When developing a strategy for deploying a video intervention targeted at people in a residential environment it soon became clear that there was not a precedent to follow. In terms of Porter’s Five Forces the intervention was neither a new entrant to an industry that already exists or a substitute for a current product. Clearly any adoption of the video approach was going to disrupt internal systems in the care organisation and result in changes to practice. From a resources and capabilities point of view any strategy to deploy video requires close collaboration between the resources of the care organisation and the video service provider. This is a challenging engagement for care providers as they are more accustomed to transactional approaches where products or services are bought to a specification. Hence, each video deployment required sensitivity to the resources and capabilities of the customer and a collaborative approach to lowering the barriers to use of the technology. For example, modifying the user interfaces of the video conferencing equipment could lower some barriers and this has been done extensively to improve the experience of the people receiving care and of the clinicians providing it.

A further challenge to any deployment of video conferencing is the initial modelling of the economic benefits. As each deployment creates a network of contacts there is no template for a specific intervention. Within health care, each disease, e.g. diabetes, has its own ‘silo’, i.e. has its own care pathway, its own specialists, seeks its own technical support and is evaluated in terms of its ability to meet disease-specific outcomes. Engaging with a particular silo is very dependent upon the context of the engagement and each deployment raises its own challenges. Therefore, before video can be deployed in the residential environment its benefits and cost effectiveness within current siloes of care have to be proved.

IGI Global Link

Hoare, Adam and Ken Eason.  A Socio-Technical Approach to Evidence Generation in the Use of Video Conferencing in Care Delivery. IJSKD 6.2 (2014): 36-52. Web. 2 Nov. 2017. doi:10.4018/ijskd.2014040103

Factors Affecting the Move to an eSystems Approach to Remote Care Delivery

Abstract:
Optimization of care provision, in the future, requires a shift from the current paternal model of dispensing care, to a collaborative model of coaching, supporting and enabling self-care and promoting independence. This will not be appropriate for all people and for all care providers but if resource utility is to be maximized, an approach must be developed that facilitates as much independence and self-determination as each person can safely and capably engage in. This requires that care provision be personalized and include broader engagement, such as social and family connections, as part of a person’s care network.

In order to facilitate a transformation of care providers into care collaborators, communications technology can play a significant enabling role as it has in other eSystems. Ubiquity of such technology across care providers, care receivers and their support networks can underpin new models of care provision. Developing a platform approach for communication and having a menu of interfaces and devices, care services can be personalized such that the technology reflects a person’s specific needs. This novel approach to person-centered communication moves away from a “one-size-fits-all” model and can facilitate combinatorial interventions. However, the move to eSystem- mediated autonomy in remote care provision is confounded by many factors. This paper will discuss the development of just such a communication platform and more than ten year’s experience will be explored in developing combinatorial innovations reflecting personal needs in two care scenarios. Through working with care practitioners and patients the platform has addressed needs in primary, secondary and social care in the UK. The current challenges in scaling the approach will be examined from the point of view of the difficulties in mapping the use of eSystems on to the fragmented nature of current care delivery.

IEEE Link

Hoare A, Factors Affecting the Move to an eSystems Approach to Remote Care Delivery Conference:  2016 9th International Conference on Developments in eSystems Engineering (DeSE), Liverpool, 2016, pp. 7-12.
doi: 10.1109/DeSE.2016.3