Covid-19: Video consults require ‘major changes to a complex system’

Switching to video consultations to prevent the spread of coronavirus isn’t as straightforward as installing a new service but “introducing and sustaining major changes to a complex system,” researchers have said.

Writing in an editorial for the British Medical Journal on video consultation for Covid-19, Trisha Greenhalgh, Joe Wherton and Sara Shaw of the Nuffield Department of Primary Care Health Sciences at the University of Oxford, and Clare Morrison from the Technology Enabled Care Programme in Edinburgh, said the implementation process would likely be “difficult and resource intensive”.

They also said strategic leads at both a national and local level would be required to deploy video systems, which should be “championed” by clinicians and professional bodies.

“If the required pace of change were slower, a quality improvement collaborative might be an excellent catalyst for spreading video consultations as an option within primary care, but time is not a luxury we currently have,” they wrote.

“Existing online communities of practice using closed platforms such as Facebook or Microsoft Teams may prove important for sharing ideas, concerns, and resources and generating collective learning.”

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Furthermore, video consultations may not always be appropriate for each patient.

In the face of coronavirus, video consultations could be useful for people with heightened anxiety; those with mild symptoms suggestive of coronavirus; those with more severe symptoms; those with chronic diseases; as well as administrative appointments.

But for those with severe illness where full physical examination cannot be deferred, or the patient is unable to use technology, remote monitoring is inappropriate, researchers added.

Video should “supplement, not replace” the phone, they wrote, adding: “Well patients seeking general advice could be directed to a website or recorded phone message.

“It may form part of a wider strategy of remote care for Covid-19 that includes automated triage, isolation of potentially contagious patients within care facilities, and electronic monitoring in intensive care units monitoring.”

Support and training

Meanwhile, support should be on-hand to manage and technical issues arising from deploying new systems, while clinical and non-clinical staff need to be appropriately trained.

“Experience in the Scottish video consultation programme suggests that in-person support may be needed to tackle both technical issues, such as assessing technical readiness and installing web cameras and monitors, and operational ones, such as identifying and redesigning key workflows—for example, for picking up prescriptions or medication, in the early stages of implementation,” the researchers wrote.

“Training of clinical and non-clinical staff and guidance for clinicians and patients on how to make the most of a video consultation, is likely to help widespread adoption. Resources should be made available now for organisations to release staff from other duties to deliver and monitor the change.”

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Primary care services, and other services looking to use video consultations, should ensure they’re using appropriate software that properly aligns with clinical workflows.

Platforms designed for video conferencing don’t provide the appropriate workflow and “may require software downloads that breach local information governance policies.”

Bandwidth, audio quality and video quality should also be considered when implementing a system.

Studies ‘irrelevant’ to current situation

Several randomised trials have shown that consultations conducted via video appointment have been successful.

These are associated with “high satisfaction among patients and staff; no difference in disease progression; no substantial difference in service use; and lower transaction costs compared with traditional clinic-based care”.

But these studies pertain to patients who have chronic, long-term conditions which require a consistent management programme, meaning they are “largely irrelevant” to the current Covid-19 situation, due to the acute and potentially serious nature of the virus.