In the 16 interviews conducted with HCPs, 7 modalities of virtual technology were discussed: teleconsultations, web-based written information, web-based online videos, E-forms, RPM, VR and M-health. The results of the TA are categorised under each modality, with their associated uses, benefits and problems in the pre-operative pathway for elective hip and knee replacement surgery.
In the following tables, lower order themes have been listed in descending order of the number of interviews they were suggested in.
1. Teleconsultations
Use-cases
Teleconsultations were highlighted useful for the “pre-assessment clinic”, especially for lower risk, “fit (and) healthy patients who don't need to come in”. Nurses can assess by asking questions “over the phone” in conjunction with the patient’s medical history obtained from their GP. Another opportunity highlighted was physiotherapy and OT appointments for teleconsultation pre-assessment; the former able to provide ongoing support for their patients both “pre and post-surgery” whilst it would be “perfect” for the latter to obtain key information sooner to allow “time to plan [for discharge]”. Information and reminders as well as questions and virtual follow-ups could be delivered via teleconsultations, as a means of communication between HCPs and patients. The information delivery could be one-to-one or via group sessions which could be “more efficient” so the patient does not have to “waste time and money on transport”.
Benefits
Teleconsultations reduce patient travel. This is particularly helpful for the elderly who may struggle more with transportation. In addition, a teleconsultation could allow the maintenance of a doctor-patient relationship, with video interaction allowing you to speak to and reassure patients, but also increasing the efficiency of running clinics. It helps to “better utilize the small services that we have got” and shortens the face-to-face consultation time by “deciding what tests and investigations need to be done from a teleconference type conversation” before the appointment.
Problems
Teleconsultation may be difficult if there are hearing or comprehension difficulties and could prevent a successful consultation. Further problems arise for “those that don't have English as a first language”.
There is a lack of visual information compared to “when you're in the hospital...it gives you an opportunity to see things”. Additionally, doctors would not be able to examine the patient. Doctors stated that it is useful to “get an overall impression of them. How are they walking? How are they interacting?”
It may be difficult to get hold of a patient due to incorrect personal details or incoherent timings. Moreover, once you have started the consultation it may be difficult to manage the consultation length and “try and stop them”. There is also the risk of being interrupted by external events, “random people could come in”.
2. Web-based written information
Use-cases
A website can be used as a platform to share information with patients such as “what to expect”, “what you need to do next or who you should contact” and “various exercises for patients to follow before they have their surgery”. This is a good resource “to equip people with as much information prior to their surgery so that they make an informed decision”.
Benefits
A website is “accessible to everybody”, as both patients and their families would be able to read the information. It is also considered more user-friendly because “of the ages of the patients”.
Problems
There is a concern surrounding “computer [digital] literacy [and] whether the patients will [be able to] access them”.
Web-based online videos
Use-cases
The sole use identified for online videos is patient education, as patients would benefit from a “video of what to expect at the appointment”. The videos could include a walkthrough of the wards; interviews with the matrons and what their day-to-day activities would involve. Videos can also improve patient preparedness for appointments as “they'll come with their medication list” which “will be quicker, more streamlined”. Finally, videos can act as an adjunct to joint school education as patients can re-watch anything missed, or it may benefit non-English speaking patients through translations.
Benefits
Patient engagement could rise as it would “condense a lot more [information] into a shorter space overall” with patients preferring a 10-minute video to reading through 10 pages of text. Additionally, because many patients are visual learners, video content could benefit them more. The modality may also aid in information retention since the videos can be watched several times and the accuracy of information can be assured with the videos scripted by healthcare professionals.
Problems
As the solution needs to be targeted at an older demographic, there are concerns regarding digital illiteracy. Online solutions remove the need for face-to-face education, which means “if it was purely done on a video, people wouldn't have the opportunity to ask questions”. A virtual solution could also pose as a challenge for compliance, as “you still have the challenge of whether the patient actually read the electronic leaflets”, an issue shared with online videos. Finally, standardized online videos to achieve patient-centred and individualised care could be difficult.
4. E-forms
Use-cases
E-forms could be used as part of OT assessment; using a “self-assessment questionnaire”, patients could submit information virtually so that “you can have the person and their information in front of you”, at their consultation. A lot of the necessary information including “furniture heights, the hip precaution information can be provided” beforehand virtually. Patients often fill in questionnaires on arrival; “medical history that could have been all sorted out in advance” using a virtual form, saving time in the clinic and directly inputting information into the IT systems. Any unclear information can be clarified on a call. Getting this information in advance can also identify high and low risk patients and thus, help plan for suitable appointments. Consent forms could also be virtualised.
Benefits
E-forms “prevent people coming into appointment and then being asked the same question over and over again”. It saves nurse’s time in the pre-operative appointments, which allows patients to “actually talk about their problem more”. It can “easily be done as a screening tool at home without the patient having to come to see us [the HCP]”, saving “a lot of wasted journeys for patients”.
Problems
There may be difficulties for patients filling in the questionnaire, leading to “blank” and missing information as they may misunderstand the questions. However, if it is mandatory, patients must either call for clarification or may mistakenly provide false information. Filling in the forms requires the patient to be “honest”, yet, patients are more likely to be open in face-to-face consultations. For it to succeed, they need to be engaged and compliant: “There might be some patients who would find it difficult or would not want to engage in that way or would need to ask someone else to do it for them”. Finally, patients may either not have access to the digital technology or they are “not [digitally] literate” enough to engage.
Remote patient monitoring
Use-cases
Numerous parameters were identified that could be measured and recorded remotely, including blood pressure, blood glucose, weight, physical fitness, heart rate, heart rhythm and respiratory rate. Due to the widespread use of smartphones, HCPs can track changes and progress in a patient’s condition as improvement in physical activity can be reassuring. It can also monitor whether they are meeting their recommended daily exercise goals.
Benefits
RPM provides HCPs with greater information to assist in management. For example, a patient may present with high blood pressure in hospital which could be attributed to ‘white coat syndrome’ whilst at home, their blood pressure may be normal. Greater availability of information also helps detects abnormalities that can be followed up by the preoperative team.
Problems
By allowing patients to record their own readings, there may be higher incidences of anxiety if patients see “error messages or abnormal data”. Finally, patients would need to be able to operate the equipment, “it should be fairly self-explanatory, but not everyone is tech savvy,” and so the equipment could be ineffective if patients cannot successfully use it.
Virtual reality
Use-cases
VR can be used for patient education and information delivery. Patients could be given a visual representation of their pathway: “how it will look in the theatre room” for example, that they would not normally be aware of. It can be used to explain difficult conditions, i.e. “maybe you could replicate delirium, or you might be able to replicate it for family members” so that patients and families are better prepared, to increase awareness and insight.
Benefits
Using VR, patients would be able to visualise their experience rather than “having a verbal explanation or a written leaflet”. This is equivalent to “almost giving an experience without having to having to do it”, which can make it “not as scary”.
Problems
Concern was raised about VR: perhaps it is “over complicating fairly straightforward things”. It could “increase anxiety” because “orthopaedic surgery [is] very scary” and knowing more may in fact make the patient more apprehensive, rather than alleviating their concerns. It may also be disorientating for the elderly: “My partner gave it [VR device] to his grandfather, and he nearly fell over because if you take somebody visuals out, if they're relying on that for their balance”.
7. M-health
Use-cases
M-health can be used to provide a range of information; it can answer “frequently asked questions and eventualities and you can see your journey pathway”. This can help reduce anxiety surrounding surgery and make “it very clear what their preoperative preparation time should be, how long they should be starved for, when they should come in, where they should go...”. It is also a “very good way of reinforcing learning”, including pre-operative physiotherapy exercises. Baseline physical information including exercise and pain can be recorded, and it can be used to encourage an increase in activity before surgery.
M-health can be used to provide important reminders such as what patients need to do in preparation for surgery and give live updates of appointment times on the day. It can also be used in “letting them know their investigation results”. For the HCPs, it can be used to collect information from the patient in the form of questionnaires and consent for the surgery. There could also be a “two-way communication” channel providing a “gateway for them [patients] to be able to ask questions back to the surgeons”, helping to reassure them and alleviate anxiety.
Benefits
M-health is beneficial because “it's accessible to someone all the time”. It is helpful to clinicians as it could be using to triage and “filter[s] out some inappropriate presentations to the unit”. This, alongside collecting information in advance, can “reduce the number of encounters necessary to the patient” where appropriate. M-health applications can also provide more personalised care by adapting to their user. It was suggested that M-health questionnaires are more engaging for patients and that they help “improve the interface for [questionnaires]”.
Problems
Problems with M-health centre around its accessibility and use. Not all “patients have smartphones and tablets” and those who do, may need somebody to help support them using and understanding it, particularly elderly patients who may also struggle logging on and remembering their passwords. It must be easy to use with a friendly interface suitable for “people that don't have great fine motor dexterity or visual issues”. The number of available Apps also added to patient’s confusion. Patients need to use the appplication and fully engage with it; it is easy for patients to use technology as an excuse or choose not to use it, and difficult to monitor their engagement with it. There is also a risk that “Once you replace humans then you lose the interaction, you lose the feel [human touch]”.