Would technology enabled remote consulting save time and add value in primary care?

Rising multimorbidity makes the evaluation and adoption of potentially time saving technologies ever more necessary, say Brian McKinstry and colleagues

Most face to face general practice appointments in the UK last at least eight to nine minutes almost regardless of the reason for the consultation.[1][2] Doctors and patients, respecting the effort involved in attending an appointment, expect a “reasonable” consultation time.[3] If someone has taken half a day off work to come and see the doctor for their results—all of which are normal—the doctor does not quickly say, “good news, it’s all clear, goodbye.” A consultation comes with an expectation of time to be spent on it, and this perception may lead the doctor or patient to raise another issue they may not otherwise have mentioned.

This is not the case for a remote consultation, where the same effort has not been expended and it is perfectly acceptable for it to last less than a minute. Telephone consultations are generally shorter and often focused on a single problem.[2] Although telephone triage of acute problems does not save time,[4] research suggests that follow-up appointments for established diagnoses, particularly long term conditions, are more efficiently carried out remotely and that patients like them.[5] However, there are two main barriers to telephone consulting: the loss of non-verbal cues and the inability to physically examine a patient. [3] Technology may provide solutions for these.

Video consulting is little used in the UK, but may overcome the loss of non-verbal cues.[6][7] It could prove useful for following up patients who don’t require a physical examination, particularly those with psychological problems where the assessment of affect is important. However, research is required to determine how easily it could be securely integrated into ageing NHS IT infrastructures, and whether it saves time or improves outcomes.[8]

Remote physical examination is a challenge. Although trials of remote monitoring of some long term conditions have been equivocal, there is strong evidence of clinical effectiveness for high blood pressure and type 2 diabetes.[9][[10] Blood pressure management may provide an exemplar for clinical pathway changes that can save clinician and patient time. Based on Scottish figures, an estimated 12 million UK GP and practice nurse appointments annually are for blood pressure checks, even though patients’ measurements of their blood pressure at home is more predictive of cardiovascular outcomes than clinic measures.[11][12]   

Self-monitoring alone can leave patients feeling somewhat abandoned, however, clinician-supported telemonitoring enhances clinician-patient collaboration and improves blood pressure control. [9][13][14] Systems now exist that allow for telemonitored data to be integrated into monthly, three monthly, or six monthly reports within normal data management routines in practice. Clinicians can phone, text, or email advice, and patients appreciate avoiding surgery attendance.[15] Recent price drops in sphygmomanometers and telemetry provide an opportunity to scale up this technology.

Remote consulting could free up time for patients with complex multimorbidity to have longer consultations.[16] We should implement those technologies that have an evidence base, albeit in an evaluative framework, and explore the potential of others, such as video consulting. The rapid growth in the prevalence of long term conditions makes the evaluation and adoption of potentially time saving technologies ever more necessary.

Brian McKinstry is a practising general practitioner and professor of primary care eHealth at the University of Edinburgh. He is co-director of SHARE the Scottish Health Research Register. His research interests include remote consulting and in particular telehealth. You can find him on Twitter @brianmckinstry

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am the clinical lead for the Scottish government funded Scale-Up BP project and have received several grants over the past 10 years to carry out research into telehealth.

David Weller, professor of general practice, Usher Institute, the University of Edinburgh.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.

Stewart Mercer, chair in primary care research, Institute of health and Wellbeing, the University of Glasgow.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.

Frank Sullivan, professor of primary care medicine, the University of St Andrews.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.

[1] Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017; 7:e017902. doi:10.1136/bmjopen-2017-017902

[2] McKinstry B, Watson P, Elton RA, Pinnock H, Kidd G, Meyer B, Logie R, Sheikh A. Comparison of the accuracy of patients’ recall of the content of telephone and face-to-face consultations: an exploratory study. Postgrad Med J 2011; 87(1028):394-9. doi:10.1136/pgmj.2010.101287

[3] McKinstry B, Watson P, Pinnock H, Heaney D, Sheikh A. Telephone consulting in primary care: a triangulated qualitative study of patients and providers. Br J Gen Pract 2009; 59(563):e209-18. doi:10.3399/bjgp09X420941

[4] Campbell JL, Fletcher E, Britten N, Green C, Holt TA, Lattimer V, et al. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet 2014; 384(9957):1859-68. doi:10.1016/S0140-6736(14)61058-8

[5] Pinnock H, McKenzie L, Price D, Sheikh A. Cost-effectiveness of telephone or surgery asthma reviews: economic analysis of a randomised controlled trial. Br J Gen Pract 2005; 55(511):119–124. https://www.ncbi.nlm.nih.gov/pubmed/15720933

[6] Brant H, Atherton H, Ziebland S, McKinstry B, Campbell JL, Salisbury C. Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice. Br J Gen Pract 2016; 66(648):e460-6. doi:10.3399/bjgp16X685597

[7] Iacobucci G. London GP clinic sees big jump in patient registrations after Babylon app launch. BMJ 2017;359:j5908. doi:10.1136/bmj.j5908

[8] Atherton H, Ziebland S. What do we need to consider when planning, implementing and researching the use of alternatives to face-to-face consultations in primary healthcare? Digital Health 2017; 2: 1–13. doi:10.1177/2055207616675559

[9] Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al  Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. PLoS Med 2017; 14(9):e1002389. doi:10.1371/journal.pmed.1002389

[10] Marcolino MS, Maia JX, Alkmim MB, Boersma E, Ribeiro AL. Telemedicine application in the care of diabetes patients: systematic review and meta-analysis. PLoS One 2013; 8(11):e79246. doi:10.1371/journal.pone.0079246

[11] Information Services Division Scotland. GP Consultations. 2017 Available from http://www.isdscotland.org/Health-Topics/General-Practice/GP-Consultations/

[12] Niiranen TJ, Hänninen MR, Johansson J, Reunanen A, Jula AM. Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study. Hypertension 2010;55(6):1346-51. doi:10.1161/HYPERTENSIONAHA.109.14933

[13] Peel E, Douglas M, Lawton J. Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients’ perspectives. BMJ 2007;335(7618):493. doi:10.1136/bmj.39302.444572.DE

[14] Paterson M, McAulay A, McKinstry B. Integrating third-party telehealth records with the general practice electronic medical record system: a solution. Journal of Innovation in Health Informatics 2017;24(4):317–22. doi:10.14236/jhi.v24i4.915

[15] Hanley J, Ure J, Pagliari C, Sheikh A, McKinstry B. Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study. BMJ Open 2013;3:e002671. doi:10.1136/bmjopen-2013-002671

[16] Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, Boyer N, McConnachie A, Lloyd SM, O’Brien R, Watt GCM, Wyke S. The Care Plus study- a whole system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: cluster randomised controlled trial. BMC Medicine 2016;14:88. doi:10.1186/s12916-016-0634-2