Digital health in primary care: risks and recommendations

Neve, Georgina; Fyfe, Molly; Hayhoe, Benedict; Kumar, Sonia

doi:10.3399/bjgp20x713837

Cited by 12 publications

(5 citation statements)

References 8 publications

(9 reference statements)

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“…Our interviews with less experienced clinicians confirmed published concerns from clinical trainees that the format of digital consultations has made it harder for them to observe and consult alongside more experienced practitioners, thereby accumulating the tacit knowledge that enables them to manage clinical risk confidently ( 58 ), as the following quote (reflecting on the collective learning that had happened pre-pandemic) illustrates:…”

Section: Resultssupporting

confidence: 62%

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

Greenhalgh

Rosen

Shaw

et al. 2021

Front. Digit. Health

112

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Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images), relationally (interpersonal interactions are altered), and clinically (patients are unique, some examinations require contact, and clinicians have deeply-held habits, dispositions and norms). Many of these challenges have an under-examined ethical dimension. In this paper, we present a novel framework, Planning and Evaluating Remote Consultation Services (PERCS), built from a literature review and ongoing research. PERCS has 7 domains—the reason for consulting, the patient, the clinical relationship, the home and family, technologies, staff, the healthcare organization, and the wider system—and considers how these domains interact and evolve over time as a complex system. It focuses attention on the organization's digital maturity and digital inclusion efforts. We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards. In contrast, our empirical data reveal that strategic decisions about establishing remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely are fraught with contradictions and tensions—for example, between demand management and patient choice—leading to both large- and small-scale ethical dilemmas for managers, support staff, and clinicians. These dilemmas cannot be resolved by standard operating procedures or algorithms. Rather, they must be managed by attending to here-and-now practicalities and emergent narratives, drawing on guiding principles applied with contextual judgement. We complement the PERCS framework with a set of principles for informing its application in practice, including education of professionals and patients.

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Section: Resultssupporting

confidence: 62%

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

Greenhalgh

Rosen

Shaw

et al. 2021

Front. Digit. Health

112

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show abstract

“…Respondents in our study described concerns about data security, confidentiality, and use of their data by third-party organisations. Studies of patients and online records shows that concern about privacy is a major issue [ 20 ]. As in our analysis, some patients do see benefits to web-based services in primary care.…”

Section: Discussionmentioning

confidence: 99%

“…Often I do not require a phone call and they can text me the information which works well for me. For example, that my prescription has been done' (Female, aged [16][17][18][19][20][21][22][23][24]. More commonly, respondents raised concerns and frustrations from their interactions with eConsultation services.…”

Section: Technology Levelmentioning

confidence: 99%

What helps patients access web-based services in primary care? Free-text analysis of patient responses to the Di-Facto questionnaire

Khan,

Pitchforth,

Winder

et al. 2024

BMC Prim. Care

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Background The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey. Methods The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021–2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses. Results Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and ‘what works for me’, a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor. Conclusions This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access.

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“…Workload, workforce and staff wellbeing UK general practice is under system stress 78 , with high and rising workload 79 , task shifting from other sectors 80 , a retention crisis 81,82 , and high levels of stress and burnout among clinicians, trainees and administrative staff [83][84][85] . Remote consulting is cognitively demanding 86 and may reduce opportunities for learning 87 . Trainees report low confidence in assessing patients by telephone 88 .…”

Section: Quality and Safety Of Carementioning

confidence: 99%

Protocol: Remote care as the ‘new normal’? Multi-site case study in UK general practice

et al. 2022

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Background: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices’ varied experiences over time as they seek to establish remote forms of accessing and delivering care. Methods: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). Results (anticipated): We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). Conclusion: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

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Digital health in primary care: risks and recommendations

Cited by 12 publications

References 8 publications

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

What helps patients access web-based services in primary care? Free-text analysis of patient responses to the Di-Facto questionnaire

Protocol: Remote care as the ‘new normal’? Multi-site case study in UK general practice

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