Modern healthcare is consuming vast resources and countries spend between 2% and 18% of their GDP on healthcare1. However, we know that the burden of healthcare continues to increase, the population is ageing and medical treatments are becoming more complex. Embracing new technologies to help focus resources may help to maintain good quality healthcare, while reducing waste.
The number of outpatient clinic appointments is growing. In the UK, in 2012-13, there were over 94 million appointments, a 3.3% increase from the previous year. Of these, 30% are new referrals and 70% are follow-ups, and trauma and orthopaedics account for 7.1 million appointments (9.3%)2.
The weight of this problem is shared by patients, as the Audit Commission found that more than a quarter of patients attending trauma and orthopaedics clinics are delayed more than 30 minutes from their appointment time before being seen by a clinician3. There is also evidence that patients are not entirely content with attending outpatient clinics. In 2012–13, did not attend (DNA) rates were 7.3%, which represents 6.9 million wasted appointments, plus 4 million follow-up appointments were cancelled by patients4.
As new models of healthcare delivery develop, it is vital to ensure that quality of care, access, and convenience for our patients is maintained, while containing costs.
What is a virtual clinic?
Searching on Medline for virtual clinics reveals lots of publications about simulated clinics for training but far fewer papers looking at the development of systems and processes to manage patient care. It is this second concept of a virtual clinic that has the potential to transform healthcare delivery.
Harrop defined the features of ‘Real’ products, services or processes as being delivered in real time, face-to-face and involving provider organisation facilities. ‘Virtual’ products, services or processes are asynchronous, outsourced and anonymous5. The 2×2 model is based on real or virtual providers as well as real or virtual patients, see Table 1.
Broadly, a virtual clinic utilizes one of the two concepts:
Synchronous communication – A clinician will interact with the patient in real time, eg teleconferencing or phone calls..
Asynchronous communication – Saving clinical time with remote monitoring, remote triage, emails and messages fall into this category Logic-based online calculators do not necessarily require clinical input for each patient.
Therefore, a telemedicine approach, conducted via videoconferencing technology fits with the features of a real clinic rather than a virtual clinic. This may not save a significant amount of clinician time, but may be very beneficial for patients.
There are good examples within medicine of patient groups being managed in this virtual manner. In Southampton, selected patients with Inflammatory Bowel Disease (IBD), with an established diagnosis, stable symptoms and not taking potent anti-metabolic drugs are remotely followed-up with questionnaires, blood tests and routine surveillance investigations. If the results are satisfactory the patient can remain under virtual clinic review. However, if a problem is identified, the patient is invited for a real clinic appointment6.
A virtual clinic approach has also been used for chronic kidney disease (CKD), another long-term condition. However, the group in Northern Ireland targeted new referrals to the nephrology department, rather than follow-ups. Patients were included where a specific diagnosis would not alter their management and their glomerular filtration rate (GFR) was satisfactory. These were reviewed by a clinician and information on drug changes, monitoring and triggers for re-referral (based on GFR) were relayed back to the GP.
Risk/benefits to patients:
Avoiding unnecessary clinic visits.
Better use of time (less time off work / travelling to hospit