Remote consultations: review of guiding themes for equitable and effective delivery

The global coronavirus disease (COVID) -19 pandemic has led to a rapid transformation in the ways in which outpatient care is delivered. The need to minimise the risk of viral infection and transmission through social distancing resulted in the widespread adoption of remote consultations, traditional face-to-face appointments ceasing almost overnight in many specialties. The transition to remote consultations had taken place far faster than anticipated and under crisis conditions. As we work towards the “new normal”, remote consultations have become an integral part of outpatient provision in secondary care. Adapting to this change in clinical practice requires a judicious approach to ongoing service development to ensure safe, effective, and equitable care for all patients. Medical societies have provided some initial guidance around effective delivery. In this article we discuss the potential benefits, limitations, types of remote consultations, and factors that require consideration when deciding on patient suitability for remote consultation in a hospital setting. We use cardiology as a specialty exemplar, although many of the principles will be equally applicable to other medical specialties.

Abstract: The global coronavirus disease (COVID) -19 pandemic has led to a rapid transformation in the ways in which outpatient care is delivered. The need to minimise the risk of viral infection and transmission through social distancing resulted in the widespread adoption of remote consultations, traditional face-toface appointments ceasing almost overnight in many specialties. The transition to remote consultations had taken place far faster than anticipated and under crisis conditions. As we work towards the "new normal", remote consultations have become an integral part of outpatient provision in secondary care. Adapting to this change in clinical practice requires a judicious approach to ongoing service development to ensure safe, effective, and equitable care for all patients. Medical societies have provided some initial guidance around effective delivery.
In this article we discuss the potential benefits, limitations, types of remote consultations, and factors that require consideration when deciding on patient suitability for remote consultation in a hospital setting. We use cardiology as a specialty exemplar, although many of the principles will be equally applicable to other medical specialties. (Curr Probl Cardiol 2023;48:101736.)

Introduction
& T he global coronavirus disease (COVID) -19 pandemic has led to a rapid transformation in the ways in which outpatient care is delivered. The need to minimize the risk of viral infection and transmission through social distancing resulted in the widespread adoption of remote consultations, traditional face-to-face appointments ceasing almost overnight in many specialties. The National Health Service (NHS) Long Term Plan, published ahead of the pandemic in January 2019, set a goal of reducing face-to-face consultations by a third in fiveyears through the creation of a more digitally-enabled outpatient service. 1 The transition to remote consultations has taken place far faster than anticipated and under crisis conditions. As we work towards the 'new normal', remote consultations are expected to remain an integral part of outpatient provision in secondary care. Adapting to this change in clinical practice requires a judicious approach to ongoing service development to ensure safe, effective, and equitable care for all patients. Medical societies have started to provide some guidance around effective delivery. 2,3 In this article we discuss the potential benefits, limitations, types of remote consultations, and factors that require consideration when deciding on patient suitability for remote consultation in a hospital setting, with cardiology used as a specialty exemplar.

Potential benefits of remote consultations
Remote clinics use telephone calls or video conferencing operating on mobile applications or online platforms, respectively, to enable real-time (synchronous) interactions between patients and clinicians at distant sites. Remote consultations offer several potential advantages to patients beyond the primary safety aim which arose from COVID-19 (see Table 1 for a summary of the potential benefits and limitations). These include greater convenience; reduced travel which might be particularly relevant for those who live in rural communities, have physical disabilities, or have care commitments; reduced time away from work; reduced cost; and greater access to services. Potential benefits for the healthcare system include increased efficiencies in time and cost; reduced waiting list times; and greater flexibility in service delivery models, something which might also be welcomed by individual clinicians. Reduced patient journeys, by car and hospital transport, are positive changes for the environment.

Potential limitations of remote consultations
The replacement of traditional face-to-face appointments by remote consultations brings with it concerns regarding clinical risk in the diagnosis and management of patients, safeguarding and confidentiality, and patient acceptability, and the need to mitigate inequality in accessing care. 4 The main limitation of all types of remote consultation is the inability to conduct a physical examination of the patient. Moreover, blood tests and other standard investigations which might previously have been performed immediately before or after the outpatient appointment such as an electrocardiogram, a chest X-ray or spirometry, cannot be readily organised. Nor can a prescription be handed directly to the patient at the conclusion of the clinical assessment. In 2018, the United Kingdom (UK) General Medical Council (GMC) updated the medical curriculum for doctors to include training on communication for remote consultations. 5 Successful consultations rely on clear and effective communication but also an empathetic patient-centred care approach, which can be challenging to achieve remotely when exchange of nonverbal and verbal cues can be absent or easily missed. 6 This increases the risk of interactions becoming more transactional with lower patient engagement and satisfaction. The GMC and NHS England have provided guidance for clinicians on factors which influence the safety of remote consultations and in which circumstances face-to face management may be preferable. 7

Types of remote consultations
Telephone consultations. Telephone is a widely available and familiar method of communication, virtually all patients having access to a landline or a mobile device. Qualitative studies have indicated that telephone consultations are usually more focused than face-to-face encounters. 8 This contributes to increased efficiency; however, it may also hinder holistic practice. Language can be a significant barrier to effective telephone consultations. In the 2011 UK Census for example, over four million people in England did not report English as their first language. Even with the use of interpretation services or with assistance from friends or family it can be difficult to obtain an accurate history, deliver information at an appropriate level, or gauge understanding by phone. The flexibility that telephone consultations offer is one of its major appeals, but this is also associated with downsides. Patients may not be available, particularly if the call is earlier or later than scheduled, or they may be in a public or work environment affecting their engagement in the process and necessitate the need for repeated calls, in turn affecting clinic schedules. Problems can also arise due to poor mobile phone reception.
Video consultations. Video consultations have the added benefit over telephone consultations of the clinician and patient being able to see each other. This facilitates nonverbal communication and allows visual examination. Video consultations are more technologically demanding than telephone consultations in device availability, set-up, and connectivity, both for the patient and the clinician. For these reasons, "tech-savvy" patients are likely to be more comfortable with them, at least initially. Digital exclusion of patients who do not have the necessary access, confidence or skills to use the service, thereby leading to unequal healthcare opportunities, are more likely to affect the elderly, those who have cognitive or sensory impairment, and the socio-economically deprived.

Triage to remote or face-to-face consultation
Over-simplified administrative allocations to appointment type, not accounting for relative benefits and limitations, have worsened tensions between quality of care and efficiency of care over the course of the pandemic. 9 Triage of outpatient clinic referrals has taken on a new importance since the shift to remote delivery, as careful assessment of referrals is required to ensure, as far as is possible, the safety and effectiveness of the encounter. Although a face-to-face consultation can be arranged after the initial remote review if required, this may lead to delays in diagnosis and treatment and is an inefficient use of resources. From a clinical perspective, the main determinant of triage outcome is the question to be addressed by the assessment, and how this is best answered, for example whether physical examination and/or investigations are required on the day. However, patient factors also need to be considered.
New patient appointments are usually the first interaction between the patient and the clinician within the relevant specialty. The accuracy and quality of the information provided in the referral is therefore key to appropriate triage. By contrast, follow-up appointments are usually made with the benefit of corroborated knowledge of the patient's history (from the first consultation or from a hospital discharge summary) and are often to discuss the results of investigations and/or to reassess symptoms, factors which may mean that a face-to-face consultation is not necessary. The nature of the information to be given to the patient ("good news" or "bad news") may also affect triage outcome.
It is important to establish the patient's preference for method of consultation and to determine the most appropriate means for communication. Commonly, this is achieved by the provision of patient information leaflets ahead of appointments. However, for many patients with cognitive or sensory impairment or those who face language barriers or literacy issues these resources may not be accessible or there may be an inability for concerns to be voiced prior to the appointment. The patient's technology and digital literacy also need to be considered for successful triage. Going forward, patient suitability for telephone and/or video consultation should be included in the referral to facilitate decision-making. Outpatient consultation outcomes should also document the most suitable method for subsequent consultations.
We provide a suggested strategy for identifying patients who are most suited to remote/virtual clinic consultations, complementing the in-depth pathway provided by the GMC (Figure 1). 7 Pathways may need to be modified based on experience, outcome data, and local healthcare system factors.

Specialist cardiology remote clinics
Cardiology is in a unique position to benefit from the advantages offered by remote consultations to healthcare organizations and patients. The increasingly widespread use of home cardiovascular monitoring by individual patients provides information which can be used to assist clinical decision-making during remote consultations. Furthermore, formal technology-enabled care services (TECS) have expanded considerably in recent years. For patients with chronic conditions such as heart failure, these services can remotely monitor patients and provide feedback to the clinician on important parameters including heart rate, blood pressure, arterial oxygen saturation, and body weight to guide management decisions. Although these data are not a direct substitute for face-to-face physical assessment, their availability circumvents to some extent the major limitation of remote consultations, they contribute important diagnostic information, are crucial to the up-(or down-) titration of heart failure medication, antihypertensive therapy, and secondary prevention medication for atherosclerotic disease, and they encourage self-management. 10 Follow-up of patients after procedures such as catheter ablation for arrhythmia, when long-term management is primarily determined by symptoms rather than by physical assessment, is well suited to remote consultations. 11 The availability of wearable technology, mobile applications, and self-monitoring devices also allow patients to record single lead ECG rhythm strips which play a valuable role in the diagnosis of paroxysmal arrhythmia. 12,13 Many patients who have arrhythmia management devices, implantable loop recorders, or pulmonary artery pressure sensors benefit from the convenience of remote device monitoring.

Conclusions
A hybrid approach which utilises both face-to-face and remote consultations is the expected model for the delivery of outpatient care in the coming years. It seems likely that the dramatic shift to remote consultations which arose due to the COVID-19 pandemic will be modulated to some degree by the advantages of face-to-face assessment for new patients, while remote consultations are retained for the majority of follow-up appointments. Careful triage is required to ensure equitable, safe and effective consultations. Changes in practice should be evaluated based on outcomes as well as patient and clinician experience.