- Telephone, with various models for assessment and triage of acute problems, with or without clinical advice; GP consultations; call-back services from a doctor to manage heavy demand in general practice, which have been increasingly promoted (see http://www.productiveprimarycare.co.uk/doctor-first. aspx) ; ‘cold calling’ to offer health education; and follow-up of chronic illness. Systematic reviewers have tended to conclude that while telephone contact for acute illness may allow minor problems to be dealt with without a face-to-face visit (and sometimes with apparent cost savings), it may miss rare but serious conditions and/or lead to higher rates of face-to-face visits in subsequent days—perhaps because even when patients have been adequately assessed, they may be inadequately reassured. This is particularly the case when call handlers with limited training are working largely to algorithm. Telephone consulting, it seems, requires considerable skill and judgement, perhaps because of lack of visual cues. Qualitative studies using conversation analysis have found that compared with traditional face-to-face consulting, telephone consultations have a more linear format and tend to focus on a narrow range of preplanned themes, with less opportunity for the patient to raise issues spontaneously.
- Text messaging, for example, for supporting young people with chronic illness; conveying results of tests or sending health promotion messages. These studies showed that the text-messaging medium was popular with patients, who used it proactively to send questions as well as passively to receive messages sent by health professionals.
- Email consultations. Systematic reviews of a large number of primary studies have confirmed proof of concept (ie, it is technically possible to consult via email) and that some sectors of the population desire such contact, but have also raised the possibility of increased inequality of access (the service is likely to be used most by young middle class patients, potentially increasing inequality of access for those who are older, poorer and with lower health literacy). Qualitative studies have highlighted professional uncertainty about safety, workload and remuneration, and about the ‘rules of engagement’ for online interaction.
- Online portals for prescription ordering, appointment booking and patient access to their online record. While these and other research studies have demonstrated proof of concept, such portals are not widely used by patients outside the research setting.
- Telemedicine, in which one part of a health service, usually in primary care, links remotely to another, usually in secondary care (eg, telepsychiatry or teleradiology). There are many proof of concept studies and examples of up-and-running services, mostly in remote regions. But the adoption, spread and sustainability of telemedicine services is often disappointing for complex reasons, including cost, logistics and subtle adverse impacts on professional roles, interactions and work routines.
- Telehealth, based in the patient’s home, in which data on biometric variables (such as blood pressure or oxygen levels) are sent to a data processing centre and (sometime later) evaluated by a health professional who contacts the patent if needed by email or telephone; and telecare, in which sensors carried by a person or installed in the home allow remote monitoring of position and/or detect smoke or flooding. Also known as ‘assisted living technologies’, telehealth and telecare are the subject of much debate. On the one hand, proof of concept (that the technology ‘works’) has been shown for many such technologies and some randomised trials have demonstrated improved outcomes such as reduced hospital admission and mortality rate.
- Combinations of the above—for example, a systematic review of the cost-effectiveness of ‘telehealth’ that included both home-based and telemedicine services, which showed that both the efficacy and costs of such services varied considerably across studies.
Virtual online consultations: advantages and limitations (VOCAL) study
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