Remote Consultations – The New Norm?

COVID-19 pandemic has presented with unique challenges and opportunities for healthcare services globally. Remote consultation has played an integral part to allow the healthcare systems to function and at the same time to adhere to the restrictions to prevent spread of SARS-CoV-2. Regulators, organisations, clinicians and patients have all adapted and adjusted to the widespread use of remote consultations across specialties and healthcare settings. In this article, we discuss the advantages and limitations of remote consultation in the NHS and its consideration in day-to-day clinical practice. Cite as: Hussain, A., Shah, S., Dave, S., Ramkisson, R., Quadri, M.F.A. (2020) Remote consultationsthe new norm. Sushruta Journal of Health Policy & Opinion 13(2) epub 26.05.2020 (pre-print v1) DOI: 10.38192/13.2.11


Introduction
The Covid-19 pandemic has changed the way we think, behave, and act. It is characterised by uncertainty, change, complexity, and ambiguity. Lockdown and social distancing to minimise the spread of SARS-CoV-2 and to keep staff and patients safe have necessitated significant and rapid changes at policy, regulatory, and practice level. One of those changes relates to remote consultation and telemedicine1,2. Within the space of a few weeks, most of us now have had the experience of using some form of remote consultation (RC).

The NHS Context
The NHS long-term plan commits that by 2024 every patient in England should be able to access digital services at least at the primary care level termed as 'Digital First'3. At the primary care level, the current NHS guidance adopts the "triage first" model using a telephone discussion. The availability of video consultation (VC) enhances the quality of information and triage, leading to better decision-making. At the secondary and tertiary care facilities we continue to have traditional face-to-face outpatient clinics for new assessments and reviews.
It is important to note that the NHS and the wider healthcare services have already been using telemedicine including remote consultation4; the only change now is the scale and the speed of adaptation and implementation. It has been widely observed that the NHS has demonstrated a highly flexible and responsive approach to deal with the pandemic.

Regulation
It is important to be fully up to date with the current General Medical Council (GMC) regulation for the use of RC. The GMC has set out 10 key high-level principles for good practice in remote consultations and prescribing that have been supported by 13 other regulatory bodies in England, Scotland, Wales, and Northern Ireland5. These principles are not new guidance, rather the existing standards adapted to the current pandemic situation.
The GMC emphasises in its guidance that in the current situation at times doctors may need to apply their professional judgment to use the resources available for consultation5,6,7. The Royal Colleges, British Medical Association, and other relevant organisation have provided guidance and updates on RC. We would advise familiarising yourself with the most recent guidance from your respective College and regulatory body.
It is vital to also consider the medicolegal implications, inherent risks, and limitations of virtual consultation8. Familiarising oneself with the available guidance and updates from medical indemnity organisation is essential for safe and defensible practice.
The NHS Information Governance team's advice is that it is acceptable to use Skype, WhatsApp, Facetime, and other commercially available products as a short-term measure during a pandemic9. We would advise that wherever possible, clinicians should consider using NHS approved platform for RC.

Technology and Platforms
The ideal technology for remote consultations is an NHS approved General Data Protection Regulations (GDPR) compliant tool, that has both the audio and visual components. The question one should ask when choosing a fully compliant platform is how urgent and important the consultation is keeping in mind considerations around safety, confidentiality, and data protection.
There are multiple platforms available both paid and free. It will also depend on your organisation that may have an approved specified consultation platform. For a highquality experience of remote consultation, the clinician requires correct equipment with good webcam, audio, and video system. Internet connectivity for both the patient and the clinician is vital for effective consultation.

Preparation
If one is not used to RC, it can be a learning curve and requires a period of adaptation. Allowing us to be curious and explore opportunities and experimenting with new ways of working is important. There is evidence that once clinicians get used to using certain platforms, the RC becomes less stressful, more efficient, directed, and focused4,10.
It is sometimes helpful to create a template that may allow for triage of patients who can be safely seen by RC. It may be helpful to send focussed questionnaires or information sheets to the patient who could return it via secure email. Such directed and focussed consultation can add significant value and save time. Some platforms have the facility for multiple participants to join the consultations for example another healthcare professional that is involved in the care or an interpreter.
Developing flowcharts based on evidence and for the most common scenarios can come handy at times when a lot of clinical decision-making will be based on observation and reports. Knowing when to avoid remote consultations is also important and having a list of scenarios and criteria to guide you may be important11.

Examination
In some specialities, RC can feel inadequate, as it is not possible to examine a patient. Given the extraordinary times with the pandemic, some creative and out of the box thinking is needed12. Patients can be advised to monitor their vital parameters by the use of mobile applications or medical devices such as blood pressure machines and glucose tests that are widely available for home use. For instance, in a virtual ADHD clinic, patients monitor their heart rate and blood pressure and send information through the application to inform their clinician. The patient receives some brief training on how to monitor their vital signs. In some cases, following a remote consultation, the patient may need to be seen face to face for the safe delivery of care. The likelihood of such an outcome should be discussed in advance with the patient.

Table 1: Documentation
Consent whether it is written, implied, or verbal. Location of both clinician and patient Technology/platform used along with limitations discussed Clarifying reasons for remote consultation Discussing circumstances to use face to face consultation Crisis or medical emergency management plan Clinic letter to the referrer, other providers and patient

Patient Perspective
It is important to ensure that patients and their carers are comfortable with remote consultation and allow them time to get used to it especially if it is their first experience. Feedback suggests that patients and carers are generally accepting of RC, can manage technical problems, understand limitations, and are generally grateful for the virtual clinical input and intervention. The other observation is that patients are honest and able to express the emotions better as there is still some distance between the clinician and patient. This is particularly important in mental health conditions 4,12,13. RC will require special consideration and more skill especially when faced with challenging communication for instance in cases where bad news has to be delivered10.

Therapeutic Relationship
At the core of every good clinical interaction is a robust therapeutic relationship, one that seeks to elicit information and allows for difficult discussions to take place. Clinicians consider the therapeutic alliance as the most important factor for a successful outcome14. A sound clinician-patient relationship also helps to improve engagement in the treatment plan and reduces the risk of miscommunication and complaints.
RC can make it challenging to establish a meaningful therapeutic relationship and clinicians may need to work harder. The rapid rollout of remote consultation during the COVID-19 pandemic has given clinicians little time to translate their therapeutic skills from their consultation rooms to their computer screens. However, clinicians are generally used to working in constantly evolving clinical environments and most would have the flexibility to adapt to this new world.
Evidence suggests that the key principles of therapeutic interpersonal relationships include therapeutic listening, responding to patient emotions and unmet needs, and patient-centeredness15. Using technology can be a challenge to developing rapport. Every interaction has the potential to elicit a countertransference reaction in the clinician and care has to be taken that this is appropriately managed so that it does not disrupt treatment16.
Patients who are used to everyday video conferencing and other technological advances will find the transition to remote consultations easy. However, clinical consultations are different from peer meetings and they might find the clinician on a screen quite distant and harder to relate to. Any barriers in language and culture can magnify this for the patient and make the process dissatisfying. Worse still, difficult transference feelings and lack of confidence might impact on their ability to take the clinical advice on board.

Trainee Perspective
The wide use of RC can have huge benefits for trainees. In providing follow up care, virtual Respiratory clinics can be set up to follow up COVID-19 positive patients after discharge. Trainees with minimal consultant supervision can manage this safely. This offers continuity of care for patients and improves their level of satisfaction. It also helps the hospital-based staff to focus on patients admitted and use resources more appropriately including Personal Protection Equipment. In a geographically widespread deanery, trainees who are located in other locations can also be recruited, thereby making better use of the manpower available.
Admission to hospital with COVID-19 is a traumatic experience for patients and they prefer being able to speak to their team from their homes after they have been discharged. In addition to reducing further exposure, RCs are proving useful in allaying anxiety in patients and improving the doctor-patient relationship.
We have observed a positive transformation in the inpatient referral process as well with the system becoming more efficient. The use of e-mails to send information and invitations securely in combination with RCs works well.
Additionally, 'COVID-19 Webinars' have been organised by different departments (Respiratory, Cardiology, Gastroenterology, Renal, etc.) bringing together a rich training experience and specialist focus on the latest information about COVID-19 including clinical updates, treatment protocols and the evidence base which appears to be growing steadily. This enhanced learning experience for trainees can be safely accessed from the comfort of our homes.
The provision of mentoring for new trainees by senior trainees is an additional feature and this can again be safely delivered by remote technology. Overall, the trainee experience of RC is positive and has opened new channels of education and continuing patient care.

Advantages
The biggest advantage of RC is the ease of access to treatment. Patients do not have to rely on transport or support from others to attend appointments. Once they get used to the format and process, they can manage the appointments with high degree of autonomy. Reduced reliance on family and friends can mean that they take more charge and responsibility for their care; this can improve concordance and health outcomes.
Patients can see their clinician from the comfort of their homes. Those who don't drive will not be disadvantaged. They have greater flexibility in terms of appointment times, as transit times will no longer need to be considered. RC also allow multi-disciplinary approach and it becomes lot easier to involve several specialists who may be located geographically distant from one another to convene and provide their clinical expertise to enhance the treatment plan11,12,13.
There are financial incentives in terms of not having to bear travel and parking costs and not having to take time off work. Patients will also benefit from the time saved. They would not have to wait unnecessarily in case clinics run over and will save time by avoiding travelling especially to regional centres and places with poor transport links. In the current COVID-19 situation, RC is the near-perfect solution to maintaining social distancing and minimising virus transmission. RC contributes to reducing the carbon footprint and can help in creating sustainable healthcare models that are environmentally friendly and greener17.

Limitations
There are complex reasons that can make RC difficult to integrate and sustain within a healthcare system including cost, logistics, and adverse impacts on professionals18. Clinicians and patients need good and uninterrupted access to the internet and power source along with a device that supports the consultation software. They might need specialist support to troubleshoot technical difficulties.
The GMC recognises that there could be potential safety risks and recommends considering if face-to-face appointment is needed on a case-by-case basis6. Defence unions also advise about being aware of inherent risks with remote consultations19.
It is not possible to perform a clinical examination apart from observation and inspection.
Although mobile applications can assist in the recording and monitoring of vital parameters like pulse rate and blood pressure, more detailed and complex examination remains out of bounds. It can also be difficult to get a full and accurate picture of a patient's mental state. However, in several areas of clinical practice e.g. dermatology, dentistry, and physiotherapy to name a few, clinicians are adapting and able to use technology to complete a full consultation. There are also issues with patient consent and autonomy. Patients may find it harder to decline appointments and may be coerced into seeing the clinician by family. It can also be difficult to fully ensure confidentiality as unbeknown to the patient, family member or friend might be in the vicinity. This can be challenging for clinician in assessing risk and potential safeguarding issues.
Patients with learning, speech, visual, and hearing impairments may require additional adjustments and support with these consultations. For certain vulnerable individuals who are socially isolated, face-to-face appointments provide some opportunity to leave their homes and meet with others. There is a risk this group who are often marginalised may become further withdrawn and lonely.
Clinicians need to be aware that patients may record the consultation. THIs is not necessarily a disadvantage when clinician is aware and ground rules considered.

Conclusion
We have made significant progress and strides in the uptake and use of technology in all aspects of our lives from consumerism to banking and beyond. In healthcare, despite the limitations and barriers that over time through research, professional experience, and patient feedback have been refined and improved, the use of RCs in clinical practice will remain. For healthcare professionals across all levels of service including primary, secondary, and tertiary care, the recent Covid outbreak has accelerated its uptake. The regulatory, indemnity, and health care organisations have supported the swift transition to using RCs to facilitate social distancing whilst continuing to provide health care. The experiences during this time will add to streamlining the use of RCs in the long-term including advances in hybrid models, risk stratification, contingency planning, and governance structures.
Following the pandemic, it is envisaged that the convenience, cost-effectiveness, and benefits in a variety of scenarios and situations will lead to the use of RCs being embedded in pathways of care. Medical schools and universities may have to look to prepare future generations to embed this way of working.