“We Must Make Sure that…the Telehealth and Digital Health Trend Does Not Widen Health Inequalities.”
Teleconsultations in health care have become something that more and more doctors are relying on because of the COVID-19 pandemic, regardless of where in the world they practice. How are doctors managing with this new technology and what lessons are there for developing countries seeking to build up their health systems? We spoke to Dr. Harpreet Sood, a practicing physician and former Associate Chief Clinical Information Officer of the U.K. National Health Service (NHS) in England, for some perspectives.
Q: What has this pandemic shown us about the role of telehealth and digital health in health care?
In the U.K. we have seen an explosion in the use of telehealth. Prior to this health crisis, teleconsultations accounted for between 5 to 20 percent of total primary care consultations, and only about 1 percent were video consultations. We have seen a complete switch, and now approximately 5-7 percent of patients are being seen face-to-face. We are seeing a similar trend in secondary care, too, where before COVID-19 there was even less usage compared with primary care.
Q: What are some of the challenges that you encountered in expanding telehealth and digital health in the U.K.?
Ensuring everyone has access to good connectivity is one big challenge. Linked to that is how to make the emerging business models sustainable. A lot of commentators are calling what is happening a radical transformation, but from my perspective as a clinician and a policy maker, it is not necessarily transformational. What this has done is take what I used to do face-to-face and given me another way of consulting my patients—it has provided me with another medium to consult with my patients. So, we need to consider: Are we going to use this moment to really radically redesign pathways and processes, or are we just putting on a "sticky plaster" because we have no other viable option?
Q: Has telehealth been effective for patients?
Telehealth does not solve all the issues we may encounter. Because of COVID-19, a lot of people, after doing a consultation remotely, are reluctant to come into a clinic to do the follow-up physical examinations, observations, or to go to the local hospital to take blood or for diagnostics. Capability is the other issue. Not everyone has the necessary skills to use technology effectively. If you have a 10- or 12-minute consultation per patient, it can take several minutes to get it all set up for telemedicine. So even though you may see more patients throughout the day, it’s a prolonged day, which naturally can be quite tiring for clinicians. There is still work to be done to evaluate the situation and to understand where such technology can be effective.
Q: What kind of training and education is needed for medical workers using telehealth?
Traditionally, we are trained as clinicians to see patients in a clinic, go through their history, gather data, ensure we have interpersonal skills, ask the right questions, and have the right clinical management. With telephone and video—especially telephone—because you don’t have a physical view of your patient, data gathering can be a challenge. You can’t see how individuals are behaving, how they’re responding, their body dynamics. Sometimes the same is true with video, too. This requires a different kind of training. We may have to collect information in different ways. This is especially the case in primary care because you often don’t have all the information at hand you would in a secondary-care setting like a hospital.
Q: How can clinicians make up for what they lose by not having that in-person encounter?
In the NHS, we have been thinking about this for a year or two. We are working to better understand how this is impacting the doctor-patient relationship in areas like trust, security, and privacy. Also, we are thinking deeply about the implications for accountability such as, what if the digital or artificial intelligence tool the clinician uses to help them make a clinical decision about a patient is wrong. Who is accountable for that? This is important because the role of the clinician is much broader than to diagnose patients, and to take on uncertainty and risk management is part of a clinician’s responsibility.
Q: What are some concerns about the future of telehealth?
We must make sure that we don’t lose out in areas like inclusivity and that the trend does not widen health inequalities. After all, not everyone has access to the Internet or smartphones or fast data, or has digital literacy to be able to use such tools. We need to make sure the tools we develop meet the needs of different demographics and income groups, and are available in different languages.
There also is a lot of learning to be done about where this technology is most effective, which types of patients it benefits most, and what metrics to use to get good evidence of its effectiveness. Also, it is important to understand how this impacts the work of the clinical staff and essentially whether it makes their job more productive and efficient, too.
Q: As developing countries develop plans in this area, what advice would you give?
Firstly, it is a very exciting space so let’s keep at it. As we build health care from a different starting point, we should create pathways and processes that rely less on physical infrastructure. Think about a decentralized approach, hub and spoke where the first port of call is a digital doorway but with more focus on providing services closer to people’s homes or even in their homes, and enhancing local communities—think about whether the patient needs to see a doctor first, or can they see another health care professional that has similar skills. Think about virtual group sessions where we bring together patients with similar conditions. This is potentially an innovative model and being explored in a few areas.
Primary and community care is where there is the greatest need, and developing countries need to think deeply about this. Technology is a great enabler to make this happen. Inclusive access is very important. Also, think about ethical concerns and trust, and do risk assessments of technologies ensure that they are good, safe, and preserve patient privacy. Based on those answers, map out what infrastructure you need. For example, in the U.K. we currently have 7,800 general-practitioner practices in physical locations, but if we were starting over now, would we need as many practices?
This article is based on a telephone interview and has been edited for conciseness and clarity.