Following the outbreak of the novel SARS-CoV-2 (COVID-19), the World Health Organization made a number of recommendations regarding the utilisation of healthcare services. In general, there has been a reduction in elective healthcare services including outpatient clinics, diagnostic services and elective surgery. Inevitably these reductions for all but the most urgent clinical work will have a detrimental impact on patients, and alternative ways of working including the use of telemedicine may help to mitigate this. Similarly, electronic solutions may enable clinicians to maintain inter and intra-professional working in both clinical and academic settings. Implementation of electronic solutions to minimise direct patient contact will be new to many clinicians, and the sheer number of software solutions available and varying functionality may be overwhelming to anyone unfamiliar with ‘virtual communication’. In this article, we will aim to summarise the variety of electronic communication platforms and tools available for clinicians and patients, detailing their utility, pros and cons, and some 'tips and tricks' from our experience through our work as an international research collaborative.
- clinical decision-making
- health services administration
- health services research
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Optimising patient care and professional practice with communication tools in the COVID-19 era and beyond
Following the outbreak of the novel SARS-CoV-2 (COVID-19), WHO made a number of recommendations regarding the utilisation of healthcare services.1 2 A joint letter by the four chief medical officers for the home nations and the General Medical Council (GMC) stated that organisations, employers and professional bodies should be ‘flexible in terms of their approach and the expectations of routine requirements’.3
In general, there has been a reduction in elective healthcare services including outpatient clinics, diagnostic services and elective surgery.4 Inevitably these reductions for all but the most urgent clinical work will have a detrimental impact on patients, and alternative ways of working including the use of telemedicine may help to mitigate this. Similarly, electronic solutions may enable clinicians to maintain interprofessional and intraprofessional working in both clinical and academic settings.
Implementation of electronic solutions to minimise direct patient contact will be new to many clinicians, and the sheer number of software solutions available and varying functionality may be overwhelming to anyone unfamiliar with ‘virtual communication’.
This article aims to review some of the ways in which online solutions may help maintain both clinical and academic work during the COVID-19 pandemic and beyond.
Remote patient consultation
Since the first documented medical telephone consultation in 1879,5 telemedicine has gradually entered most forms of healthcare consultation. Specialties such as dermatology,6 cardiology7 and orthopaedics8 have used mobile applications and remote assessment for a number of years. The most recent National Health Service (NHS) England Long Term Plan anticipates widespread use of online services within the next 5 years9 including video consultations. These may replace face-to-face follow-up consultations when appropriate, saving patients time, travel and cost.
COVID-19 has catalysed alternative working methods and telemedicine has rapidly taken centre stage. Applications of telemedicine include telemonitoring (signs or symptoms sent electronically from patient to provider in another location), remote interpretation of radiology and other investigations, as well as consultations and departmental meetings via video conference.10
Furthermore, telemedicine has been used in the COVID-19 pandemic through the triage, coordination and management of suspected or confirmed cases of the disease.11 Artificial intelligence allows the referral of moderate-risk to high-risk patients to nurse triage while scheduling video visits with established or on-demand providers, avoiding travel and exposure. Theoretically, sicker patients could be identified at home and placed directly in hospital beds, bypassing the emergency department.12 A similar prognostication system for patients with sepsis13 and those with critical illness in the intensive care unit14 has previously been demonstrated.
The UK NHS 111 service was originally established with a view to triage patients online as a part of telemonitoring and is currently the first port of call during COVID-19, with over 400 000 phone call triages performed and the completion of over two million online symptom assessments.15
Telemedicine has the additional advantage of maintaining the value of the workforce quarantined at home by allowing them to continue their scheduled outpatient visits as telephone and online consultations. This strategy depends on clinicians having reliable remote access to hospital records via an electronic system, and lack of such access represents one of the hurdles that needs to be overcome before telemedicine can be implemented more widely and consistently.
Several software applications have enabled the safe application of telemedicine to outpatient clinics; for example Clinic.co (free to those with an nhs.net email)16 and Attend Anywhere (free trial followed by an annual subscription service),17 which are purpose-built platforms for video consultations mimicking traditional clinics. Clinic.co provides a one-time link which can be forwarded to the patient’s phone to access, at which point the video consultation starts. In Attend Anywhere, services are provided via a ‘waiting area’ representing a different specialty or service including primary care, consultant-led clinics or allied health professional services. Similarly, a virtual ‘waiting room’ allows patients to be aware of their number in the queue. No specialist software is required for either program, as these are web-based and are fully end-to-end encrypted. Patients require access to an internet connection and a device that can allow video calling. The availability of services like these are increasing across the UK in multiple specialties, including in prison healthcare.
The GMC Good Practice Guidance for patient care and safety, including confidentiality, applies regardless of whether patients are reviewed physically or electronically.18 19 However, there are some specific considerations for telemedicine, particularly with regards to data protection.20 Today, electronic clinical interfaces are protected by higher tier security, and are designed with data security and confidentiality in mind.21 A number of safeguards are in place to ensure compliance with General Data Protection Regulation 2016/679 Guidelines and the Data Protection Act 2018 including data and email encryption, triple password protection, secure remote access ‘tokens’, and limitation of the types of data stored.22 23
Compromise to any of these measures can result in loss of data security, and subsequently patient confidentiality and trust. While the GMC and medical defence unions have vowed to support doctors during the COVID-19 pandemic,24 25 clinicians must remain cognisant of the heightened risks to data security with ongoing use of telemedicine in the future. Accordingly, clinicians and medical indemnity companies should ensure that clinical indemnity cover includes telemedicine in all its formats. In terms of communication tools, Microsoft Teams has recently been implemented free of charge across the NHS for a limited time period during the COVID-19 pandemic and is therefore protected and monitored by the NHS Secure Boundary, ensuring that patient data and clinical services are robustly secure.
Practical considerations and patient care
Telephone consultations are technologically more straightforward than video consultations but are limited by the lack of visual cues and the inability to show patients radiological images or drawings to complement discussions. Video consultations overcome these drawbacks, but at the cost of greater technical complexity, including issues surrounding the patients’ access to appropriate technology to support the consultation. Appropriate preparation is essential in scheduling and allocating patients to this method of communication (see table 1).
To ensure telemedicine stays relevant in healthcare even after the COVID-19 pandemic, it is essential to introduce dedicated training of clinicians specifically for remote consultations. A recent review examining published curricula for telemedicine26 highlighted that this may be provided using well-developed, comprehensive curricula in both undergraduate and postgraduate training within the contexts of commonly used frameworks such as the CanMEDS roles (The Canadian Medical Education Directives for Specialists)27 and ACGME (Accreditation Council for Graduate Medical Education) Core Competencies.28 The review found that the most frequently taught topics in telemedicine curricula were the use of technology, performing clinical examination and history taking via telemedicine, communication with patients and specific topics specific to medical specialties. The authors concluded that a comprehensive telemedicine curriculum based on a competency-based, outcomes-orientated framework was required. Another paper assessing the utility of a telemedicine-specific teaching class for new surgical residents in the USA found that students had increased confidence in target communication skills and that direct observation and immediate faculty feedback were particularly useful for students’ confidence in performing telemedicine consultations.29
Another important consideration is that of the patient experience in using telemedicine and video consultations. The acceptance of these new technologies by patients as well as clinicians is key to its’ success in the future. Patients will require adequate training and documentation provided on how to use the software being used. They may be apprehensive regarding the lack of face-to-face communication and therefore have perceived difficulties in communicating their concerns and issues. It is likely that acceptability of telemedicine consultations will increase over time as they’re increasingly employed. Furthermore, knowledge and awareness of situations in which telemedicine may not be appropriate is key for clinicians. Situations such as those in which a patient does not have access to appropriate technology or there are other difficulties present such as patients who are hard of hearing or the need for clinical examination must be anticipated and triaged appropriately to ensure clinical care is not compromised.
Virtual team working
The other area in which online solutions have come to the fore during the COVID-19 pandemic is in enabling interprofessional and intraprofessional teams to work together successfully, even if doing so remotely. Central to this paradigm is the use of software platforms which enable efficient team organisation and communication that can be thought of as ‘anchor software’. Anchor software acts as a central hub and messenger which can link other software tools to allow features such as video conferencing, document editing and task scheduling. Functions such as interteam messaging, task reminders and links to cloud data storage for document sharing provide additional utility over and above existing phone calls, text messages or email. Furthermore, these systems allow multiple people to join discussions from separate locations including across sites or institutions (figure 1).
Anchor software systems each have unique characteristics and selling points which influence the choice of one application over another. Ideally, all platforms should be compatible with desktop, laptop and mobile use, allow messenger communication, and enable task allocation including management of deadlines.
Examples of anchor software include Slack communication software, Microsoft Teams, Asana collaboration work management platform, Monday and Teamwork. Of these, Slack and Microsoft Teams are two of the leading platforms sharing functions such as free file storage and the ability to subdivide teams into separate groups of people working on specific projects.
However, there are also key differences between these systems and a number of advantages in using them over traditional forms of communication (table 2). Microsoft Teams is primarily designed to work with Microsoft-based applications such as Office, Outlook and Meetings. The majority of key functions are embedded within the platform so once installed users should be able to perform the usual functions without installing additional software. Conversely, Slack allows integration with a wider variety of third-party applications which may allow a more bespoke system that can be built up to suit the particular needs of an individual team. Many basic functions of add-on third party applications are free.
Messaging within Microsoft Teams and Slack allows workstream-specific conversations to be established. This avoids contacting the whole group with every communication and helps to ensure messages reach the right audience in the most timely manner. Individual posts can spawn ‘threads’ so that multiple discussion topics within a workstream can be better organised.
The use of anchoring software and accompanying project management and communication software can facilitate the following examples of teamworking.
Multidisciplinary team and departmental meetings
With the centralisation of cancer services, remote multidisciplinary team (MDT) meeting functionality is already relatively widespread. However, this commonly takes place between sites and the current COVID-19 situation may not allow a large number of people to be in the same room at the same time at each individual site. Videoconferencing should be arranged in a similar manner to a face-to-face meeting, with a central coordinator organising an appropriate meeting time and ‘place’ (in this instance, organising and distributing a link that others can join with). Electronic records enable simultaneous access of relevant medical history, imaging and other investigation results during a remote MDT by each specialty or clinician. This has the potential for improved decision-making as each individual has access to all the clinical data rather than the more standard process whereby only a brief summary is usually presented to the MDT.
Prior to the meeting the coordinator should test the software to ensure any technical issues are rectified. During videoconferencing, it is important to mute all non-speaking participants to prevent them speaking over one another especially when it is difficult to signal to the moderator. During the call, all participants should ideally use headphones to prevent speaker ‘echo’. Participants can also use the messaging feature within the videoconferencing app to signal comments or questions thereby minimising interruptions. Participants should ensure good lighting, a plain background and as little noise as possible to avoid distractions.
Academia, project management and document editing
Academic departments and research collaboratives have been required to alter their practice during the COVID-19 pandemic due to restrictions on face-to-face working, which could impact on research productivity. Being able to collaborate in a shared space will help maintain research activity. Anchor platforms and their associated software applications can provide a forum for project-specific discussions among research groups and allow certain activities to continue. With the exception of most lab-based research, many research activities typically carried out in person can be carried out using these software, allowing important projects to be completed, manuscripts to be written and grant applications to be submitted.
Perhaps the most important function within anchor software is the integration of collaborative document creation and editing. Documents can be attached or ‘pinned’ into the relevant chat stream allowing a central version of the document which team members can edit and collaborate on with individual team member changes visible as they occur in real time. Aspects of the document requiring specific input can be set as tasks for the relevant team member to identify and complete within the document.
Teams can thus be convened in the virtual space and allow projects and tasks to be managed with lists, assignees and deadlines. There are multiple task management software applications that can be added to Slack (eg, ToDo, Sendtask) without a cost, which allow project coordinators to manage collaborators more effectively. Trello is a project management software program integrating with both Slack and Microsoft Teams, and although full Gannt chart functionality (a bar chart illustrating a project schedule and progress) requires a fee, basic functions are adequate for most small teams. Project management software allows an overview of tasks that need completion, who is assigned to complete them and the timeline for completion.
Unrelated to this work, The BURST Research Collaborative would like to acknowledge funding from the British Journal of Urology International, The Urology Foundation, Ferring Pharmaceuticals Ltd, Rosetree’s Trust and Action Bladder Cancer UK.
Contributors The BURST Research Collaborative comprises members and contributors around the world. Members use a number of communication tools to deliver high-quality international research projects, with face-to-face meetings only occurring on average twice a year. HLR and DS are clinicians using other similar electronic platforms for both teaching and patient consultation use in the current climate. DS and VK conceived the initial idea for the article. KDC led the article writing in collaboration with all other authors. All authors critically revised the article and approved the final draft. KDC is the corresponding author and VK is the guarantor.
Funding VK is an Academic Clinical Lecturer funded by the United Kingdom National Institute for Health Research (NIHR). JMN is a Doctoral Fellow funded by the United Kingdom Medical Research Council (MRC).
Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing is not applicable as no data sets were generated and/or analysed for this study. This is a review piece and as such there are no data sets available.
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