Implementation of web-based hospital specialist consultations to improve quality and expediency of general practitioners' care: a feasibility study

Telemedicine as a tool for continuing medical education

BACKGROUND

There is a growing interest in the use of digital technologies to foster learning in the health professions, along with the drive to expand teleconsultations arising from the COVID-19 pandemic. This study aims to explore whether telemedicine between levels of care can act as continuous medical education (CME) tool for general practitioners (GPs) and hospital consultants at the referral cardiology department.

METHODS

This qualitative study was embedded in an organizational case study of the introduction of a new service model in the Portuguese health system. Semi-structured interviews were audio-recorded and pseudonymized. The transcribed interviews were stored, coded, and content analysis was performed in MAXQDA.

RESULTS

A total of 11 physicians were interviewed. GPs and cardiologists recognized that telemedicine between levels of care could act as a CME tool. Although they departed with different expectations, telemedicine helped them collaborate as a multidisciplinary team, exchanging feedback about clinical decisions, and constructing knowledge collaboratively. Telemedicine also supplemented existing learning meetings. The consequences of technology adoption may be viewed as a result of the actors involved (including the technology itself), characteristics of the context (including the organization), and an interaction between such factors.

CONCLUSION

Teleconsultations can be a learning opportunity for the health professionals involved. Our findings suggest that, in the context of the Portuguese health system, telemedicine as a CME tool helped to build multidisciplinary teams which exchanged feedback and constructed shared knowledge to improve patients' outcomes. It also helped to identify practice-changing contents to be included in face-to-face educational meetings.

Impact of digital interdisciplinary consultation on secondary care referrals by general practitioners: a protocol for a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Optimal collaboration between general practice and hospital care is crucial to maintain affordable and sustainable access to healthcare for the entire population. General practitioners (GPs) are the gatekeepers to specialist care and patients will visit hospitals mostly only after referral. However, a substantial part of these referrals may be inappropriate, as communication between GPs and medical specialists can be challenging and referring patients may be the most obvious action for a GP to perform.A new digital platform (Prisma) connects GPs and specialists in interdisciplinary groups and facilitates asynchronous, accessible and fast teleconsultation within the group. No previous research has been done to evaluate the impact of this new platform on the referral rates to the hospital.

METHODS AND ANALYSIS

A stepped-wedge randomised controlled trial (RCT) will be performed in Zwolle region in the Netherlands to analyse the effect of introduction of the platform on rate of inappropriate referrals to orthopaedic surgery. In four steps, GPs in the region will be given access to the platform. GPs will be part of the control condition until randomisation to the intervention. According to our sample size calculation, we need to include 18 practices with 1008 patients presenting with hip and knee symptoms. Routine care data of hospital registrations will be analysed to calculate the rate of inappropriate referrals (primary outcome). Secondary outcome are costs, primary and secondary care workload, posted cases and user satisfaction. Alongside this quantitative analysis, we will evaluate patient experience, facilitators and barriers for use of the platform.

ETHICS AND DISSEMINATION

The medical ethics review board of University Medical Center Groningen (UMCG), the Netherlands (METc-number: 2021/288) has confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to the process evaluation because the study does not involve randomisation of patients or different medical treatments (letter number: M21.275351).

TRIAL REGISTRATION NUMBER

NL9704.

Audiovisual teleconsultation for patients with epilepsy in primary care in rural Germany: a pilot study on feasibility and acceptance

Background

In rural areas, epilepsy patients have limited access to specialist secondary care. Substantial travel and waiting times of several hours are common. Communication between general practitioners (GP) and specialist epileptologists regarding diagnosis and treatment is further complicated by the high workload on both sides and the different prioritisation of treatment goals. This study aims to investigate the feasibility of an interprofessional audiovisual patient-doctor teleconsultation, and its acceptance in clinical practice in patients with epilepsy in a rural region in Germany.

Method

Ten patients participated in telemedicine consultations in their GP practice. The practice was located in a sparsely populated region of Mecklenburg-Western Pomerania, and was equipped with technical equipment specifically procured for the project. An explorative qualitative interview was conducted with all participants. We based this paper on the consolidated criteria for reporting qualitative research (COREQ).

Results

Despite initial uncertainties on the patients’ side regarding the consultation setting, all participants found the teleconsultation helpful. Some patients were initially intimidated and felt slightly overwhelmed by the attention provided and the technology used (multiple HD cameras, large high-resolution screens). However, during the consultation, they felt supported by their GP and were satisfied that their needs were addressed in an appropriate and timely manner. The hardware used was not felt to be a nuisance or to interfere with the conversation between doctor and patient. Patients also appreciated the time saved and the organisational convenience compared to a visit to a university outpatient clinic. Most consultations led to therapeutic consequences. Some patients seemed to benefit particularly, for example those who needed a medication change.

Conclusion

This pilot study provides first evidence that teleconsultations between patients, specialists, and GPs are possible in rural areas. Interprofessional collaboration between GPs and epileptologists can improve the care of patients with epilepsy. Further research should investigate the effectiveness and efficiency of interprofessional telemedicine consultations for epilepsy and other conditions.

Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach

The recently developed scheduled mobile-telephone referral model (DETELPROG) has achieved especially important results in reducing waiting days for patients, but it has been decided to explore what barriers and positive aspects were detected by both primary care physicians (PCPs) and hospital attending physicians (HAPs) regarding its use. For this, a qualitative descriptive study was carried out through six semi-structured interviews and two focus groups in a sample of eleven PCPs and five HAPs. Interviews were carried out from September 2019 to February 2020. Data were analysed by creating the initial categories, recording the sessions, transcribing the information, by doing a comprehensive reading of the texts obtained, and analysing the contents. The results show that DETELPROG gives the PCP greater prominence as a patient’s health coordinator by improving their relationship and patient safety; it also improves the relationship between PCP and HAP, avoiding unnecessary face-to-face referrals and providing safety to the PCP when making decisions. The barriers for DETELPROG to be used by PCP were defensive medicine, patients’ skepticism in DETELPROG, healthcare burden, and inability to focus on the patient or interpret a sign, symptom, or diagnostic test. For HAP, the barriers were lack of confidence in the PCP and complexity of the patient. As a conclusion, DETELPROG referral model provides a lot of advantages and does not pose any new barrier to face-to-face referral or other non-face-to-face referral models, so it should be implemented in primary care.

Online Consultations Between General Practitioners and Psychiatrists in the Netherlands: A Qualitative Study

Objective: To examine the nature and scope of questions about psychiatric patient cases submitted by general practitioners (GPs) to an established online consultation platform and to determine if they could have been answered by consulting existing clinical guidelines. Methods: All anonymized psychiatric cases submitted by GPs to the online electronic Prisma platform between September 2018 and November 2019 were examined in a mixed-methods study. Descriptive statistics and qualitative thematic analysis were used, followed by axial coding to arrive at overarching themes to characterize cases. Results: Of the 136 included cases, 44.1% concerned female patients and about half concerned patients aged 31-60 years. Common psychiatric disorders were depression, attention deficit hyperactivity disorder, sleeping problems, sexual disorders, and eating disorders. The first response was usually given within 2 h (interquartile range, 0-14.3 h), with 86% answered within 24 h and 95% within 48 h. Qualitative analysis revealed four themes, namely "type of question," "cases in relation to current clinical guidelines," "case complexity" and "the doctor being pressured." Type of question comprised diagnostic, therapeutic, and referral questions. Notably, for 44.1% of questions no current clinical guidelines was present and 46.3% of cases were deemed complex in nature. GPs were willing to share their experiences of coping with being pressured by patients. Conclusion: The findings of this study support the potential for an online electronic consultation platform to facilitate feasible and useful interprofessional consultation between GPs and psychiatrists for a broad range mental illnesses and questions of varying complexity.

Approach to the Patient With Thyrotoxicosis Using Telemedicine

CONTEXT

The potential for endocrine care via telemedicine has been recognized since the early 2000s when clinical outcome data demonstrated improvements in glycemic control with telemedicine. The widespread use of telemedicine during the COVID-19 pandemic has pushed telemedicine beyond diabetes care and into clinical areas with a paucity of published data. The evaluation and treatment of thyrotoxicosis heavily relies on laboratory assessment and imaging with physical exam playing a role to help differentiate the etiology and assess the severity of thyrotoxicosis.

CASE DESCRIPTION

We describe a patient presenting for evaluation of new thyrotoxicosis via telemedicine, and describe modifications to consider for thorough, safe evaluation via telemedicine.

CONCLUSION

Telemedicine may be an ideal way to assess and treat patients with thyrotoxicosis who are not able to physically attend a visit with an endocrinologist but still have access to a laboratory for blood draws. Potential challenges include access to imaging and high-volume surgeons if needed. Clinical and economic outcomes of telemedicine care of thyrotoxicosis should be studied so that standards of care for endocrine telemedicine can be established.