To mark the 100th anniversary of the invention of the telephone, the Lancet in 1977 published a discussion paper on the use of telephony in health care. The paper reminds us that the first words uttered by Alexander Graham Bell were for medical assistance as Bell, talking to Watson, had just spilt sulphuric acid (necessary to power the telephone battery) over himself and said “Mr Watson, come here, I want you” (Aronson, 1977). Notwithstanding that doctors were the first profession required to have a telephone to be available on-call, they were not universally in favour of this new-fangled technology.
Doctors of the day were concerned that patients would want the doctor to consult with them via the telephone instead of attending the surgery in person (meaning a reduction in fees); doctors were also worried that they would be inundated with calls. However, despite these reservations the technology took off, and very rapidly the telephone became an invaluable addition to the doctor’s armoury. Doctors were able to communicate with their patients (at least the very few who had access to a telephone), with each other – sharing information and gaining support across hospitals and with the authorities – and were able to provide early and quick warnings about new outbreaks of communicable diseases.
Fast forward 40 years and it’s not the telephone which is shaping medicine, but digital (electronic) consultations. Given how easily the public have embraced e-commerce and e-banking, many wonder why this has taken so long. Answering my own question – it’s because dealing with the complexity and sensitivity of health care is vastly more complicated than dealing with the purchase of a new shirt or booking a holiday. Health care has little room for error; it is a safety critical industry, and this is irrespective of the space (click, call or contact) in which it is delivered.
Empowering the patient to self-care is the achievable holy-grail of e-consultations
All e-consult systems must, as standard, be able to pick the rare abnormality or red flag symptom from the sea of normal (after all if they are to emulate GPs this is what we do all the time). Missing the subarachnoid haemorrhage in amongst all of the headaches is not an option, even if done by a computer using algorithms. Equally a system that just refers or diverts most contacts to a ‘safer’ alternative (such as 111, GP care, A&E care and so on) which is what many GPs are concerned about, is also not an option. E-consultations must divert not duplicate care if they are to find a place in our crowded consulting rooms. Empowering the patient to self-care is the achievable holy-grail of e-consultations, meaning that the busy GP can spend more time with those patients who really do need face to face care.
The digital space is blooming. There are many products being tested – and rightly so at the start of this exciting time. The platform developed by my own practice, eConsult, initially as an internal tool for use within The Hurley Group’s 15 practices, is now being used by more than 350 practices across England. Patient and GP feedback is helping continuously shape what is offered and we are constantly learning, adapting and improving what can be achieved. The journey to this date has involved developing clinical templates, algorithms, governance and competency frameworks for doctors using the system, ensuring indemnity is unaffected and improving the technological platform on which everything is based. We have learned how to launch in practice, how to embed in the myriad different models practices operate and how to best promote to patients and doctors. Now we are learning how to evaluate its potential.
Over 75% of eConsults are closed without the patient needing to attend the surgery
Of course, it is early days to show what has been achieved. Even given the quarter of a million e-consultations to date conducted by eConsult, this is but a fraction of the 1 million face-to-face appointments done by GPs across England every day. However, use is growing on a daily basis as GPs feel more confident to allow patients access to this technology. Our results are promising. Over 75% of eConsults are closed without the patient needing to attend the surgery. Of the remaining 25% who see a GP, appointments are more efficient as the patient’s history has already been taken – using the patient’s own words to describe what they feel is their problem. We have even managed to restore morale, with GPs enjoying the variety the e-consultations give, and the possibility of working together in our virtual practice; centrally processing eConsults across our 15 practices, enabling us to manage demand across a number of sites.
The telephone changed the clinical landscape 40 years ago, digital is redefining it once again. We are on the brink of a paradigm shift in how we consult with our patients – a shift which will enhance rather than reduce what we can offer patients. Just as the telephone, in the 20th century enriched all of our lives, so too will digital consultations in the 21st century. With continual improvement, it will never be time to ‘hang up’.
Aronson, SH. The Lancet on the telephone. 1876-1975 Medical History, 1977, 21: 69-87
Feature photo: Markus Spiske