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 hospital).
Avoids long time in waiting room.
Increased involvement in decisions.
Safety and efficacy of care may be compromised.
Risk/benefits to the healthcare provider:
Spare capacity can be used to see more new patients.
Better use of facilities and staff.
Fewer DNA’s / cancelled appointments.
Ability to collect and utilise validated measures of patient outcome and evaluation.
Orthopaedic virtual clinics
Glasgow has pioneered the introduction of virtual fracture clinics. They recently published their analysis of 202 patients with suspected Mason type I or II fractures7 and have also presented their process for all fractures and have audited the performance. Since October 2011, no routine appointments for the fracture clinic were generated from the emergency department (ED). All referred patients are screened in a virtual clinic. Patients only attend fracture clinic for ‘something to be done’. The virtual clinics are run three times per week, ED notes and images are reviewed by a Consultant. A diagnosis and plan are recorded, a senior nurse phones each patient the same day, virtual discharge or a real OP appointment is arranged and a letter is sent to the patient and GP. This process is logged in a database and juniors from Orthopaedics and ED can attend for training.
Approximately 60% of the traditional system clinic appointments were unnecessary and 10% of appointments were appropriate for review in a nurse-led fracture clinic, rather than a consultant-led sub-speciality fracture clinic. Patient satisfaction with the system is high (over 90% positive) and the paper focused on elbow injuries followed the cohort up and found the process to be safe with only two patients requiring late surgery. One required excision of an impinging radial head fragment and one required radial head replacement for late displacement.
In Trafford, the virtual clinic process has been designed with elective orthopaedic follow-up care in mind. Patients undergoing arthroscopic subacromial decompression are followed up using the PROMs 2.0 system. This secure, web-based platform can be used to collect patient reported outcome measures (PROMs) patient evaluation measures and other important data such as operation details and comorbidities. For ASAD, patients are asked for pre and post-operative Oxford shoulder scores (OSS)8 and EQ5D scores (a validated, generic measure of health status)9.
Once patients have undergone ASAD and had their initial two-week clinic review to identify early complications, the PROMs 2.0 system tracks their progress by the patients’ responses to the outcome scores. Using in-built logic, based on the minimally important clinical difference (MCID) of the OSS, patients are given choice about their follow-up. If the PROMs 2.0 system detects that a patient has achieved the MCID compared to the pre-op score, the patient is given the information that they are showing evidence of good progression. They can then choose to continue with their rehabilitation and virtual clinic follow-up, avoiding a routine real clinic appointment. Alternatively, if they are not reassured and content with their progress, they can indicate this and a real clinic appointment can be arranged. If the outcome score does not improve by the MCID then a real clinic appointment is generated to see if there is a problem.
This process has been validated and over 90% of patients who achieve a good improvement in their scores choose to avoid routine clinic appointments. Patient feedback is very strong. The process was evaluated using the Picker patient experience questionnaire with 94% positive responses10.
This system is versatile and the group in Trafford have also utilised the PROMs 2.0 to estimate quality-adjusted life years (QALYs) gained by patients undergoing ASAD. The EQ5D questionnaire is NICE’s preferred method of estimating QALYs and deem a treatment as being cost effective if it costs £30,000 or less per QALY. On average, patients’ health status improved by 0.24 and the mean follow up was for 15 months. Therefore, a conservative estimate of the QALYs gained is 0.3 as the improvement in health is likely to persist beyond the 15 months. Cost per QALY can be calculated based on the reference costs for the procedure (£1,307) or the tariff payed to the trust (£2,368) giving a range of between £4,356 – £8,347 per QALY. This provides evidence that ASAD is a cost effective intervention.
In conclusion, virtual clinics offer the opportunity to redesign care pathways to reduce waste, give patients choice, obtain validated measures on outcome while delivering cost effective, safe, highly valued care.
References:
- http://data.worldbank.org/indicator
- Hospital Outpatient Activity 2012-13. December 12, 2013. Health and social care Information centre (HSCIC). http://www.hscic.gov.uk/catalogue/PUB13005
- Audit commission 2003. Outpatients – Review of National Findings. http://archive.audit-commission.gov.uk/auditcommission/nationalstudies/health/other/pages/outpatients.aspx.html
- Harrop VM, Virtual healthcare delivery: defined, modeled, and predictive barriers to implementation identified. Proc AMIA Symp. 2001: 244-48
- Hunter J, Claridge , James S, Chan D, Stacey B, Stroud M, Patel P, Fine D, Cummings JRF. Improving outpatient services: the Southampton IBD virtual clinic. Postgrad Med J 2012; 88: 487-491
- Mark DA, Fitzmaurice GJ, Haughey KA, O’Donnell ME, Harty JC. Assessment of the quality of care and financial impact of a virtual renal clinic compared with the traditional outpatient service model. Int J Clin Pract, October 2011, 65, 10, 1100-1107
- Jayaram PR, Bhattacharyya R, Jenkins PJ, Anthony I, Rymaszewski LA. A new “virtual” patient pathway for the management of radial head and neck fractures. J Shoulder Elbow Surg 2014, 23, 297-301
- Dawson J, Rogers K, Fitzpatrick R, Carr A. The Oxford shoulder score revisited. Arch Orthop Trauma Surg. 2009;129:119–123
- Whitehead SJ, Ali S. Health outcomes in economic evaluation: the QALY and utilities. British medical bulletin. 2010;96:5-21
- Crispin Jenkins et al, The Picker Patient Experince Questionnaire: Development and validation using data from in-patient surveys from five countires. International Journal for Quality in Health Care 2002; Volume 14 Number 5; 353-358
James Wilson, Speciality Trainee in Trauma and Orthopaedics, NW Deanery.
Mr Bibhas Roy, Consultant Orthopaedic Surgeon (shoulder & Elbow), Central Manchester Foundation Trust
