COVID-19 and primary care

Consultations during COVID-19: a review of current telemedicine platforms

In the face of COVID-19, primary care has had to adapt at an incredible pace. With lockdown and social distancing measures in place, face-to-face GP consultations have had to be replaced by new forms of socially distanced care. Recent developments in technologies, such as video calling, mean that there is greater scope in what GPs can achieve remotely.

Consultation platforms

This crisis and the need it has created for telemedicine platforms has meant that many existing platforms are expanding their capabilities. An example of such a platform is AccuRx.¹ Originally a health tech start-up that had an SMS tool allowing GPs to text their patients securely, it built a new video consultation service in the early weeks of the pandemic in the UK, as GPs were preparing for this new phase of remote care delivery. The video consultation service was, as of end of March, being used by over 80% of practices in the country.²

Importantly, this platform allows integration into both Emis and SystmOne electronic patient record systems which are commonly used by GPs. AccuRx allows GPs to text their patients’ mobile phones, creating video links via which they can securely consult. Files can also be attached and NHS links sent to the patient’s mobile phone. Feedback on the platform has been positive, with many initially sceptical clinicians finding it an excellent solution to the problems faced in consulting in this time.

Other such platforms (table 1) are also in use. These are all solutions assured by the NHS to comply to a sufficiently high standard for video consulting.

As well as the expansion of current platforms, the needs of this crisis have seen the launch of completely new ones. Going one step further than previous platforms is Nye Health, launched in March 2020.⁴ This is an NHS compliant browser based telephone and videophone, allowing clinicians to call their patients from any device, anywhere. This bypasses the complicated security requirements of the other platforms such as AccuRx, which require use on an NHS device, or a personal device with a remote secure working system installed, such as Away From My Desk.⁵ Despite Nye’s launch just a few months ago, thousands of appointments have been booked through it, with over 10 million patients being covered. Its launch has far-reaching implications for the future of telemedicine.

Video conferencing

Outside of the patient doctor consultation, technology has allowed improvements in remote patient care in other areas. GPs in London have said that they have benefitted from an increase in communication between clinical team members, facilitated by online video conferencing. This has been particularly important when clinicians have had to self-isolate themselves. A practice in London has used Microsoft Teams for daily meetings to discuss new guidelines, problems and cases.

Another video meeting platform, Zoom, has been used similarly – although this platform comes with some security concerns meaning patient specific details must be avoided in Zoom meetings. One such case of Zoom’s use is exemplified by a GP in Oxfordshire, who has trained a large team of medical students to call the practice’s high risk and vulnerable patient lists to ensure they are receiving sufficient support. The video meeting platform Zoom has been used in this project to facilitate meetings between the medical students and their supervising doctors every day, to discuss any issues faced in the calls, and reflect on learning points.

GPs in London are similarly reaching out via telephone to their elderly and vulnerable patients. Those on the at-risk registers, such as those with histories of domestic violence, are also being contacted. Parents of children under 12 have been texted, and provided with a traffic light system informing them of when they need to bring their children in. All of these are examples of remote care being implemented to proactively support patients in the community in this difficult time.

A 2018 study into the advantages and limitations of virtual online consultations in the NHS showed them to be safe, effective and convenient. However, a major conclusion from the study was that the process of rolling out and scaling up such consultation services across the NHS was going to be hugely complex and challenging.⁶ This pandemic has, in some ways, forced this integration – the old adage “necessity is the mother of invention” has never been truer. The current climate has created a need for e-consultation services, and for these to be integrated into appointment systems – and it has happened.

Strengths

Video consultations have a number of benefits over telephone consultations in that they provide visual cues, as well as facilitating the building of a better rapport between patient and doctor, therefore allowing greater provision of reassurance to the patient.⁷ They are also time-saving when compared to face-to-face consultations. In an age where so many aspects of daily living can be accessed online (from buying groceries, to learning, to a large part of the way we socialise), it is certain that many will welcome this change. Particularly appealing to younger patients, telemedicine allows a more rapid and convenient incorporation of healthcare into increasingly busy lifestyles where service on-demand is a growing expectation.

Weaknesses

Telemedicine is not without some major pitfalls. The same study that found video conferencing to be superior to telephone consultations also found technical issues were common. The assumption of platforms that facilitate video conferencing, such as AccuRx, is that patients will have a smart mobile phone that they are comfortable with using, so can follow the video link and consult with their GP. Particularly for the elderly, and the less affluent, this has the potential to pose a large barrier to healthcare access. In the current climate, GPs have found this is particularly worrying, with COVID-19 posing its greatest risk to their elderly patients, and those with co-morbidities.

For patients without smartphones, the alternative is for the doctor to text or to speak over the phone, returning to the limitations of classical telephone consultations. And even though e-consultations do have advantages over telephone consultations, they themselves have limitations as compared to face-to-face consultations. Doctors run the risk of missing subtle signs, and diagnosis can be challenging with videos not always being of sufficient quality to allow signs, such as rashes, to be seen clearly. Moreover, even with video calling, the issues surrounding those who are hard of hearing still stand as they do with telephone consultations, again leaving the elderly patient group at greater disadvantage. Another difficult aspect of video calling to consider is security and privacy. Vulnerable patients may not be alone during the call without the doctor’s knowledge, for example those at risk of domestic abuse.

There are some concerns about the security of the Zoom platform. Doctors’ personal laptops may be much faster and less likely to face technical issues than clunky NHS laptops, however the systems that need to be installed to allow sufficient security on these slow the device down immensely. They also often require physical security features, such as tokens, which at the beginning of the COVID-19 crisis were in short supply.⁸ The introduction of Nye Health’s free and secure tool to allow access on any device could usher in a solution to this issue. Interestingly, many countries, including the US, are formally relaxing laws surrounding data protection regulations for video during the crisis.⁹ This will revert after the crisis, which will impact the ease with which video consultations can be implemented.

Threats

Although the rapid onset of the world of telemedicine brought about by this pandemic has much potential for future improvement of patient care – greater convenience for patients, reduced infection rates, access for prescriptions to be issued electronically to any pharmacy – there are some potential threats. These include increases in mis-diagnosis, or missed diagnoses, as a result of reduced clarity of clinical examination. Others issues are the potential for an unsupportable elevation of patient expectation of doctor availability, and increases in healthcare inequality.

Opportunities

Whether or not the benefits telemedicine brings outweigh the potential risks, this pandemic has put us in the unique situation where we have been motivated through necessity to try it out. It is therefore imperative, wherever possible, that as we continue with this new form of care delivery, that we audit and gather information on what has worked and what hasn’t. This will help direct target delivery in the future when the plight of the pandemic is subsiding. The pandemic creates an opportunity for the benefits of telemedicine to be maintained and be a positive legacy of this time.

The change in the attitude of patients towards the NHS and their use of its services is a further space of opportunity for helping to solve the problem of the overburdening of primary care, and the NHS as a whole. Currently, remote methods are being used to contact huge swathes of patients, who are wary of visiting their doctor at this time, and contact explains how they can know when they are sick enough to visit their doctor. Such patient education could have far-reaching implications for future care. Can it aid patients to better use their NHS, to reduce the burden not just in times of COVID-19, but for the future?

An even bigger question stands. If COVID-19 continues to pose a great threat, and new forms become a yearly occurrence – could this usher in a new era of medicine? If physically gathering patients together under one roof is no longer a viable system of care, will this become our new normal? And if we can, in fact, return to our normal method of consulting – how much of telemedicine will remain in clinicians’ practice? New platforms such as Nye Health hold the potential to streamline health provision by digitally linking patients with their clinicians in an intuitive and accessible way. This platform’s future development goals have far-reaching implications, with plans of using this increased digital integration to establish a greater relationship between patients in their healthcare data, engaging patients in the wider community of research and science.

The rapid transfer to e-consultations, despite being challenging, has showcased the incredible flexibility of the primary care workforce to adapt to completely new situations. Almost overnight, GPs have been planted in a brave new world of telemedicine and e-consultation, having to navigate new platforms and technologies to interact with their patients and deliver them the care they need. Ordinarily changes such as these would take many months to implement – in reality, changes have been implemented in just days. This is a huge undertaking that should be applauded.

Madeleine Oliver
4th year Medical Student
University of Oxford
([email protected])

Other articles from COVID-19 Bulletin 2:

COVID-19 and immunology

• vaccine development
• expert report on COVID-19 and immunology research

COVID-19 and cardiorenal disease

COVID-19 and diabetes

• Diabetes UK position statement
• COVID-19 diagnostic glucose/lactate sensor in development

COVID-19 and mental health

COVID-19 and heart valve disease

References

1. AccuRx. www.accurx.com
2. Thornton J. (2020). Covid-19: how coronavirus will change the face of general practice forever. BMJ 2020, 368.
3. NHS Digital. Approved video consultation systems. https://digital.nhs.uk/services/future-gp-it-systems-and-services/approved-econsultation-systems#advice-on-using-video-consultation-systems (last accessed 11th May 2020)
4. Nye Health https://www.meet.nye.health/
5. Away From My Desk https://secure.awayfrommydesk.com
6. Shaw SE, Wherton J, Vijayaraghavan S, et al. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. Southampton: NIHR Journals Library 2018, Health Services and Delivery Research 2018, Number 6.21. https://www.ncbi.nlm.nih.gov/books/NBK507677/ (last accessed 11th May 2020)
7. Donaghy E, Atherton H, Hammersley V, et al. Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care. Br J Gen Pract 2019;69:e58694. https://doi.org/10.3399/bjgp19X704141
8. Thornton J. Covid-19: how coronavirus will change the face of general practice forever BMJ 2020;368:m1279. https://doi.org/10.1136/bmj.m1279
9. US Department of Health and Human Sciences. Notification of Enforcement Discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html (last accessed 11th May 2020)