Teleclinics in rheumatology introduced during the first lockdown phase of the COVID-19 pandemic of 2020

Rapid delivery and roll out of teleclinics

With the COVID-19 crisis in March 2020, an early decision was made by our Trust to start teleclinics. Staff who were self-isolating considered ways of taking the load from those working in the frontline. For those in the frontline, teleclinics allowed flexibility in conducting clinics in the face of a fluid and fast-changing ward environment.

The teleclinic set up underwent a privacy impact assessment (PIA) in line with the General Data Protection Regulation (GDPR) Act. The process of data collection and access to patient/physician identity were approved by the Trust Information Governance Committee prior to the delivery of the teleclinics. Good information technology (IT) support ensuring good network connection and the availability of clinical documentation, pathology and radiology results all in one place with a single login was key in ensuring successful rapid delivery of teleclinics. Steps were taken to increase capacity for remote login to the electronic patient record (EPR) and other programmes for offsite working. New SIM cards were issued for phone conversations with patients and others. The video software NHS Attend Anywhere was quickly deployed across the Trust. Group conferencing software (Windows Teams) was downloaded onto Trust laptops used at home.

We provided in-house training to all staff at the start of the pandemic. ‘How to’ guides were produced and access to training materials for the software was given.

All the virtual clinics were recorded and run through the EPR, as were the documentation and ordering of investigations, with results were returned to the clinician's result folder through the Virtual Clinic episode on EPR. Blood test forms and prescriptions were sent to patients directly at home with their clinic letter from the virtual clinic. Patients could attend their GP surgery to have blood tests and collect or have their prescription delivered to them at home.

Our departmental administrative team has provided key system support, such as confirming patient details and setting up appointments. Some administrative teams are also proactively scanning future clinics to offer patients the option of teleclinics. This has been recorded on the EPR which improves accuracy in coding and activity data.

Patients were notified of their teleclinic appointment by email, text or phone and requested to have an up-to-date list of their medications ready for the teleclinic. The practicalities of setting up teleclinics rapidly and urgently in during the COVID-19 pandemic in March 2020 are shown in Box 1.

Triage and streaming of both new referrals and existing follow up lists are important to ensure that the right patients are seen in the right setting. The administrative team have accessed all referral letters and follow up clinic lists. Practitioners not in the frontline were tasked to triage and stream patients to teleclinics. For this purpose, a list of inclusion and exclusion criteria for patients suitable for teleclinics was developed. This is shown in Box 2.

Structured preparation by the practitioner before the teleclinic is essential in order to maximise the consultation time during the teleclinic. A suggested preparation structure is shown in Box 3.

Benefits of teleclinics

We found that offsite teleclinics can shorten consultation time, as there are often fewer distractions and consultation can be more focused. We feel that routine booking of everyone who asks for an earlier appointment into a teleclinic avoids overloading of FTF clinics, with subsequent FTF appointments (especially if urgent) becoming more focused as those attending have already been screened and had provisional plans put in place.

Old age and presence of comorbidities were not a reason for us not to offer teleclinics. We found that this group were shielding at home during the pandemic and were available through this medium. The age range in our study was 17–92 years and the mean number of comorbidities was greater than one. The availability of telephone or video systems was more important than age or comorbidities. For older or immobile patients, we propose that remote consulting is dramatically easier than attending clinic and this may correct inequality of access.

We confirmed that teleclinics are useful for triage and support of patients with chronic pain problems, helping us to decide if inflammatory arthritis patients who had an increase in pain were indeed having a joint flare and would benefit most from an FTF appointment or a different approach. It was clear that a key benefit of teleclinics is in triage and streaming of patients, allowing direction of patients to the part of the service most appropriate to their needs. Future research will show if this reduces FTF clinic attendances and provides capacity to see new patients.

Teleclinics support patients on patient-initiated follow up (where the patient determines the need to come back to clinic) by allowing intermediate discussion encounters, as well as offering opportunities for other patients to discuss concerns they may have if there is a long interval before their next booked FTF appointment. All patients from teleclinics are considered for patient-initiated follow up if appropriate. Teleclinics promote consultant and nurse ownership as all queries can be directed to the appropriate practitioner who will be able to deal directly with the patient.

We do not pretend that teleclinics take less time overall, but clearly they take up fewer of the hospital's physical resources, and the reduction in practitioner travelling time to our many outlying clinics would compensate for any extra time spent doing teleclinics. Teleclinics undertaken at our main base increases the availability of practitioners onsite for other tasks between teleconsultations. This supported clinicians who needed to be on the main base site during the pandemic. Most important decisions can be made, investigations initiated and vital triage performed at teleconsultation provided guidelines are followed. The decisions that can be made are shown in the results in Table 1.

Risks of teleconsulting

We found that with teleclinics confidentiality issues are paramount. It is impossible to be sure that one is maintaining confidentiality if one cannot see or hear who else is in the room. Only video software that meets NHS security standards should be used. The patient should not be in a location where they can be overheard. The video consultation is not recorded, just as FTF appointments are not recorded.

There may also be safeguarding issues if the patient is not able to be frank in the presence of others about problems they are having at home. Teleclinics may miss important physical signs that could only be picked up by hands-on physical examination. Video consultation nevertheless offers the possibility of picking up visual cues and may allow limited clinical examination. The absence of careful clinical examination may matter a great deal to many patients and may result in loss of patient confidence.

We also feel that situations that require the establishment of a relationship of trust between patient and practitioner are often not suitable for teleconsulting. For example, we are not yet satisfied that it is safe to initiate a new DMARD or biologic treatment without up-to-date hands-on clinical information, which can only be available at FTF consultation. This applies to many other situations of uncertainty where trust is required, such as challenging explanations of a new illness. This is an important factor to consider in new patient consultations. It is also likely that a lack of practitioner confidence or experience could be amplified in a teleconsultation, leading to a lack of patient confidence in the process.

There was limited time in the first few weeks of the pandemic to arrange translators or the presence of another household member to assist with language, hearing, vision and access to technology. There could have been possible selection bias as a result of this. In the latter half of the study and beyond, we have been able to arrange translators or another relative staying in the same home to assist in these areas and thus mitigate against the reduced access. Patients were asked if they had any disability that might prevent or hinder participation in virtual clinics and reasonable adjustments were made. While video consulting may well be beyond quite a lot of people, this applies less to phone consulting. Hearing problems were solved by having a partner or friend present with the patient's consent. As both telephone and video clinics are accessible through mobile phones or laptops, patients were given prior notice to find an area or room away from crowds. The mobile phones and laptops allowed patients increased mobility to participate in virtual clinics away from crowded living. We are aware that as the COVID-19 pandemic and lockdown eases, there may be less risk to attending for FTF appointment. We believe the case selection would not change significantly as the inclusion criteria for teleclinics (Box 2) are based on clinical indication instead of risk stratification against infection from COVID-19. We used the COVID-19 time to develop a protocol that we think will be suitable for use in the long term after the pandemic (Box 3).

We are evaluating the risks of teleconsulting by recording any harm that may have come to patients attending virtual clinics and comparing the frequency against FTF clinics. We have developed a risk register to record any harm or near misses from virtual clinics.

Further evaluation

There is huge potential for teleclinics to be implemented widely post COVID-19. However, further research on the long-term benefits, sustainability and limitations of teleconsultation in internal medical specialities is needed. Areas for future research include which patients prefer teleconsultations and which prefer FTF, and in what circumstances.

Clinical outcomes using patient-reported outcomes and experience measures (PROMS and PREMS) should be measured in teleclinics using FTF as controls, although selection bias may interfere with the results. Adverse events from teleclinics will need recording and evaluation.

Does teleconsulting reduce clinic workload, for example by reducing the number of FTF consultations per patient in the next 18 months compared with FTF? Again, selection bias may be an issue and will need to be considered. Time spent on FTF clinics versus teleconsulting (including all administration except checking and responding to results) will need to be assessed.