Joint consulting through teleconferencing - feasible, effective, popular?
William Clayton, Robert Harrison, Paul Wallace
Department of Primary Care & Population Sciences, Upper 3rd Floor, Rowland Hill Street, London, NW3 2PF
The Problem
There is a recognised need to improve communications between hospitals and primary care. Both this and the need to evaluate new technologies has been recognised by the NHS1. Referrals from general practice form the major part of the workload at this interface, with between 6 and 10% of consultations in general practice resulting in a referral, thus generating 10 million referrals a year. The research in this area suggests that communications are prone to problems and missed educational opportunities. There has been criticism of the poor quality of written communications, in both directions, which are also prone to delays and going missing2. Studies have also shown that the GP, patient, and consultant can form different views as to the purpose and the outcome of the consultation and this can lead to subsequent misunderstandings3. The delay in receiving any feedback on the referral also results in most of the educational opportunity being lost.
Some Solutions
More effective use can be made of the telephone. There are some GPs and specialists who do make extensive use of the telephone, but in general it is not used effectively and projects to increase use have not proved very successful4. It is perhaps most useful when the doctors already know each other and a face-to-face rapport has already been established.
Since the inception of the NHS, it has been recognised that a good professional dialogue can be achieved by getting together to discuss a case. For this reason, joint home visits (domiciliaries) were enshrined in the original architecture of the Health Service. More recently, Outreach Clinics have been developed, also aimed at getting the professionals together. There has been a marked increase in these since the advent of fundholding. What evidence there is shows that outreach clinics do little to improve the interaction between GPs and specialists5. They are also expensive in consultant time, by taking the specialists out of their highly productive hospital outpatient setting and adding travel costs. Likewise domiciliary visits, which in 1988 cost an estimated £20,000,000 in consultants' fees alone; apart from being costly, they nowadays generally lack the added benefit of being joint6. One district found that fewer than 5% of their domiciliaries were carried out jointly7.
But when they can be achieved, genuine joint consultations have demonstrable benefits. A recent randomised controlled trial in the Netherlands8 looked at conventional orthopaedic consultations and compared them with consultations where the GPs were present in the outpatient clinics with their patients. There were approximately 150 consultations in each group and the patients were followed up for a year. The study found that the intervention group had fewer investigations, treatments and subsequent interactions with the Health Service. This timely piece of research was instrumental in developing our ideas about how to achieve joint consultations.
With the advent of modern electronic communications, the increasingly ubiquitous nature of the PC on our desks, the wiring up of the NHS and the development of teleconferencing technology, a possible solution presents itself. Would it be possible to arrange joint consultations, without either doctor having to leave their consulting room, and the patient having an appointment at the surgery instead of the hospital? We decided to call this new mode of joint consulting "Virtual Outreach", and imagined that it could be used for a wide variety of initial and follow-up outpatient appointments, but that the GPs would only choose to arrange a small number of their referrals this way.
A research project is born
In order to test the feasibility and acceptability of this idea, a project was established at the Royal Free Hospital in London. Six group practices, including one total fundholder with no previous referral behaviour to the Royal Free, were recruited, together with ten hospital specialists who could each be available for a regular slot each week. A special hotline made it easy for GPs to ring in referrals and set up the consultations. These would usually take place within the week. The Royal Free had three ISDN2 lines servicing twelve extensions. To connect up the consultants, a PC-based video-conferencing unit was mounted on a trolley and wheeled into the consultant's office at the appointed hour. He would dial up the surgery at the appointment time and the consultation would take place with the GP introducing the patient. The consultations were evaluated by self administered questionnaires to all three participants. These were designed to evaluate concurrence of views of the purpose of the consultation, technical performance and participant satisfaction.
Some Results
A total of 54 teleconsultations were conducted, typically lasting 15 minutes, and distributed across the specialties as follows:
SPECIALTY Number SPECIALTY Number DERMATOLOGY 11 ORTHOPAEDICS 5 UROLOGY 8 ENT 5 GASTRO-ENTEROLOGY 7 ONCOLOGY 2 PAEDIATRICS 7 PSYCHIATRY 1 ENDOCRINOLOGY 6 GYNAECOLOGY 1
Four of the early consultations were subject to severe technical failure, such as loss of sound, or vision, or both. The average response rate for the questionnaires was Patients 83% (44), General practitioners 79.2% (42), Consultants 86.8% (46).
Acceptability to the Doctors
Some of the findings indicating the levels of satisfaction of GPs and Consultants are presented in Table II:
Table II:
Doctors who agreed: GP (%) Consultant (%) Communication was adequate 41 (98) 40 (87) Information I obtained was 39 (93)* 42 (93) adequate Rapport with the patient was good 38 (93)* 41 (89) I was satisfied with the patient's 39 (95) 40 (87) response Quality of the sound was 34 (81) 25 (53) satisfactory Quality of the vision was 33 (79) 25 (53) satisfactory Overall quality of the telelink 38 (90) 27 (71) was good The arrangements worked well 39 (93) 31 (82)
*not all questions were answered in each completed questionnaire
Acceptability to patients
Patient satisfaction was measured in both general statements, and through specific parameters such as rapport, shyness, confidentiality. The two overall measures were the patients' general satisfaction rating and their willingness to teleconsult again. These responses are shown in Tables III and IV.
Table III
Positive Neutral (%) Negative (%)
(%)
After using the television link
this is how I would feel about 35 (83) 7 (17) 0 (0)
using it again...
In general I felt my experience
of using the television link 40 (95) 0 (0) 2 (5)
was...
Table IV
Agree (%) Neither (%) Disagree (%)
I felt the consultant could
understand my problem 35 (85) 2 (5) 4 (10)
I was able to say all I wanted 35 (85) 1 (2) 5 (12)
I was worried other might be 3 (8) 6 (15) 30 (77)
listening
I felt shy and nervous about 8 (21) 3 (8) 28 (72)
speaking
I could not say all I wanted 8 (20) 1 (3) 31 (78)
Discussion
This initial study has shown it is possible to set up a service delivering teleconferenced consultations to local surgeries. A reasonable number of consultations were achieved during the study period of five months, and the views of doctors and patients participating were consistently favourable across a range of parameters.
We feel that this supports the concept of using teleconferencing to bring about the renaissance of joint consulting. We now plan an experiment designed to evaluate the following hypotheses:
Compared with conventional consultations joint consulting through teleconferencing will:
The technology
The equipment is based on standard desktop PCs with a minimum specification of a 486 processor with 8 Mb of RAM. The communication channel is ISDN2 available over the public service phone network for a £400 installation charge. ISDN2 phone lines carry 128 kilobits of data a second. By comparison, an analogue line carries 8 kilobits. 128kbits is still very modest compared with other telemedicine applications, particularly image-based programmes, where 2 megabits is common. However, such a broad bandwidth is very expensive, whereas this sort of technology is currently available off the shelf for under £4,000. It can be expected that teleconferencing facilities will be the next "added value" to mass-market multimedia PCs without significantly affecting the price. Although the sound and image are fairly crude, this did not seem to matter much to the users; once the link was established, the consultation proceeded with little regard to the equipment.
The future
Despite the need to improve communications and the likelihood of being able to demonstrate one way of effectively tackling this problem, there are considerable difficulties in predicting its widespread uptake. These lie in two main areas:
On a more positive note there are constructive trends that will encourage implementation, and although telemedicine has been around in various forms for a long time and seen many false dawns it appears there is now a convergence of several major trends so that it finally looks to have arrived in reality:
So to conclude with the vision that inspires the research: Telemedicine, in its multifarious guises, is coming, and teleconferencing may succeed in bringing about the renaissance of joint consulting and thereby do something to improve communications between primary and secondary care.
We are grateful to the following GP and Consultant colleagues for their help with this project:
Dr Harry Chester Dr Pierre Bouloux
Dr John Church Dr Owen Epstein
Dr Stephen Corcorane Dr David Flynn
Dr Karen Fraser Mr Nicholas Goddard
Dr Rhiannon Lloyd Dr David Harris
Dr Claire Mitchell Dr Alison Jones
Dr Angela Parker Prof. A MacLean
Dr Alan Selwyn Dr Paul McLaren
Dr Jeremy Sandford Mr Robert Morgan
Dr Paul Wiseman Mr Robert Quiney
Prof. Brent Taylor
Dr Viv van Someron
References
1 Anonymous. Research for Health: a research and development strategy for the NHS. Department of Health, 1991 (Abstract)
2 Roland M. Communication between GPs and specialists. In: Roland M, Coulter A (eds.). Hospital Referrals. Oxford University Press, Oxford, 1992:108-122
3 Hopkins A, Wallace P. Referrals to medical outpatients: Different agendas of patients, general practitioners and hospital physicians. Royal College of Physicians, London, 1992:
1-103 (Abstract)
4 Roland M, Bewley B. Boneline: evaluation of an initiative to improve communication between specialists and general practitioners. Journal of Public Health Medicine 1992; 14:307-309
5 Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in general practice. Br Med J 1994; 308:1083-1086
6 Littlejohns PC. Domiciliary consultation - who benefits? J R Coll GP 1986; 36:313-315
7 Fry J, Sandler G. Domiciliary consultations: some facts and questions. Br Med J 1988; 297:337-338
8 Vierhout WPM, Knottnerus JA, van Ooij A, et al. Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders. Lancet 1995; 346:990-994