To help determine the most beneficial VHTs and their relative impact in the pre-operative pathway, it is necessary to compare the results of the TA with the existing literature. These will be discussed and categorised according to VHT modality.
Teleconsultations were placed as most useful in the pre-operative assessment clinic, with the greatest benefit being reduced travel and cost savings for patients. Clinicians were particularly satisfied with this benefit as it does not compromise face-to-face contact. The TA also indicated that staff would find tele-consultations helpful in identifying high-risk patients aiding earlier triaging and optimisation, potentially reducing last minute cancellations. This is supported by Tam et al whose use of teleconsultations resulted in a drop in cancellation rates from 10% to 3.1%25. Our TA also highlighted that tele-consultations prior to clinic appointments can inform nurses of which tests need to be organised for each patient, reducing waiting times and delays for both patients and staff. Both these suggestions are supported by the literature and utilise important demand management concepts of ‘filter and focus’, triaging patients according to risk and need, allowing for demand forecasting and optimal resource allocation. By optimising the ‘back office’ support services that organise and administrate patients, clinics can be run with minimal variation and on schedule, reducing patient waiting times.
Another important concept identified was the use of teleconsultations in the continuous monitoring of patients throughout the pre-operative pathway. HCPs felt that virtual follow-ups between appointments would be beneficial to patients that are unsure about whether to report any changes in their health or wellbeing. This suggestion mirrors the case report by Blozik et al26, showing the effectiveness of tele-consultations in avoiding last minute cancellations and post-operative complications by providing a contact point between appointments and before their surgery. By staying ‘in touch’ with the patient, the organisation takes responsibility for the entire care cycle, improving patient experience and outcomes, whilst reducing costs incurred by complications and cancellations27.
The TA highlights important barriers to the use of teleconsultations in clinical practice. One major barrier is the inability to physically examine patients. Although literature shows high levels of concordance between virtual and face-to-face examination, these examinations were only relevant to the anaesthetic context and did not consider orthopaedic examinations and more extensive tests28. Furthermore, clinical staff also expressed the importance of seeing patients in person, to implicitly judge their physiological reserve and general condition. The TA also indicated a use for tele-consultations in the daily workflow of OTs, although there is no supporting literature for this use-case.
Despite great promise, the limitations in physically interacting with patients as well as concerns about scheduling alongside current appointment systems makes implementing tele-consultations an extremely challenging task. HCPs also discuss alternative, less challenging technology modalities able to fulfil the benefits previously discussed. This, coupled with a lack of data economically evaluating tele-consultations, means that whether they are the answer therefore remains unascertained.
2. Website-based education: Written information
The only use identified for this technology was patient education. A lack of interviewee enthusiasm resulted in a lack of data on this topic, perhaps due to how well-established this technology is.
HCPs interviewed described the main benefit of websites as easy access. Literature further demonstrates that information-based websites are a more effective means of delivering information, resulting in a better-informed patient29, increased patient satisfaction and reduced anxiety30.
Interviewees cited digital illiteracy as the largest problem with this technology, confirmed by Yin et al31. Additionally, literature shows that website-based information needs to be updated on a regular basis, particularly as there is often unverified or inaccurate information available online31.
3. Website-based education: Online videos
HCPs identified patient education as the sole use for online videos. This concept has been previously tested, where it demonstrated a reduction in pre-operative anxiety, whilst better preparing patients31. HCPs concurred with this, identifying online videos as more engaging and increasing information retention. HCPs also pointed out that they could ensure information accuracy by producing the video themselves.
However, the aforementioned study failed to identify problems for online videos. The interviewees provided greater depth illustrating how digital illiteracy would be a roadblock. They also expressed concerns that the patient would be unable to ask questions, the videos would not be tailored to patients and they could not guarantee that patients watched the videos.
Waller et al32 discussed using E-forms to collect information from patients prior to their consultation. This correlated with the HCPs who suggested this be done at multiple stages of the pathway including for the surgeon, the nurse and the OT. They also suggested using information collected via E-forms to risk-stratify the patient earlier. In addition, one HCP wanted surgical consent to be taken via this method as well. This use has evidence base behind it, as Issa et al.33 showed how electronic consent was preferred by patients whilst being more standardized, easier to read and comprehensible. More recently, St John et al.34 demonstrated their use at separate hospitals in the UK in various departments and that electronic consent improves quality and consistency of documentation.
The interviewees cited saved time and reduced duplication of information as the key benefits of E-forms. They enjoyed the ease of use of E-forms and appreciated the impact it could have on increasing continuity of care. This is supported by Staroselsky et al. 35, who suggested that getting patients involved in reviewing and submitting their own health information could result in a more complete EHR. Literature also suggests that collecting information would provide a more holistic view of the patient32.
HCPs suggested digital illiteracy as a potential barrier. However, they stressed access to technology is rising across age groups and could be improved with adequate support. This is supported by a study from Deloitte which showed that 77% of over 55s own smartphones, with this number expected to continue rising36. The interviewees also suggested that data collected may be inaccurate and patient compliance may be an issue.
5. Remote patient monitoring
A comparatively newer technology, HCPs supported the use of RPM in monitoring patient prehabilitation by measuring physical activity. Darvall et al previously illustrated this by incorporating pedometers37. However, they noted that a major limitation was that walking may not be possible for people about to undergo knee or hip replacements37. Interviewees further suggested that RPM could play a bigger role in the pre-operative pathway in monitoring a patient’s health prior to surgery (e.g. blood pressure and blood glucose).
HCPs also had positive impressions of the modality, noting that having constant RPM would increase the pool of information available to them, saving time collecting information whilst allowing more informed decisions. RPM could also alert HCPs to any emergency abnormalities. Furthermore, a major study run by the UK government, showed that home-based telemonitoring devices delivered a reduction in accident and emergency (A&E) visits, a drastic 45% reduction in mortality rates, as well as an 8% reduction in tariff costs38,39.
The problems with RPM make its feasibility questionable. The aforementioned UK government trial showed high implementation costs of RPM with cost savings that were statistically insignificant38,39. As well as this, the interviewees also identified the potential of medicolegal issues regarding data collected. There was the possibility also, that the patient may be unnecessarily alarmed by abnormal but insignificant readings. Again, digital illiteracy was acknowledged as a potential barrier.
6. Virtual reality
The sole application of VR in the pre-operative pathway for elective orthopaedics identified by the interviews was educating patients about before, during and after surgery. As demonstrated by Bekelis et al.40, VR used this way improved satisfaction, preparedness levels and decreased anxiety.
Interviewees, however, were more sceptical about this technology, particularly in the elderly demographic. They highlighted that the elderly may struggle with this futuristic technology and may find it disorientating. They also had concerns that VR could even increase anxiety for some patients by over-burdening them with information.
M-health was one of the most popular modalities amongst HCPs interviewed. M-health encompasses all the aforementioned technologies to some extent and could be incorporated into an M-health solution. Interviewees suggested the use of m-health to monitor patient adherence to pre-operative protocols outside of hospital, a use supported by research41. They proposed using M-health to give patients instructions and reminders regarding their pre-operative preparation. They further advocated a larger role for M-health in other parts of the pathway including patient education, pre-appointment questionnaires, as a means of communication as well as for RPM.
The interviews agreed with literature that M-health could help reduce duplication of information and reduce the workload of HCPs, particularly if the application was linked to EHRs41. However, HCPs added that there were multiple additional benefits of M-health, including its increased accessibility for the patient, the fact that it is more engaging whilst also providing more personalised care.
From the interviews, it was discussed that M-health intervention could present problems as people may not have access to technology or may not know how to use it. In addition, they stated it would be difficult to get patients to comply with the application. The last point is in direct contrast to the study by Kim et al.41, who showed that adherence rates for M-health were similar and could be improved further if the benefits of the application were evident to the patient.
Implications to practice
The TA shows what HCPs think the best uses of VHT are and which modality they would most like to see delivering these. The results of the top five uses and their preferred associated modalities are shown in Figure 8.
A series of audits by the Royal College of Anaesthetists47 showcases two key problems that could be tackled by these virtual interventions:
- Triage & pre-assessment
- Patient education & preparation
Hence, we propose the following recommendations.
- Patient triaging and pre-assessment: Patients should be provided with an interface with access to a virtualised triaging e-form. This would be based on the current triaging guidelines. The triaging tool would collect information on a patient’s demographic, co-morbidities and lifestyle, and automatically triage patients into low, medium and high-risk groups according to the ASA48. This could have a significant impact on workload, with 1 in 6 patients undergoing hip and knee replacement being considered low risk patients49. Patients will thus be filtered down the appropriate channel allowing more efficient time and resource allocation. After triage and preassessment, patients should have a communication portal with a nurse from the surgical team which they can use until the day of surgery to get updates or ask have their concerns addressed. This could prevent on-the-day cancellations.
- Virtualisation of patient education and preparation: Information normally provided during a ‘Joint School’ could be incorporated into an m-health app. Better informed patients lead to better prepared patients, reduced cancellations and improved post-surgical outcomes50. This would reduce the resource burden, as despite high initial investment costs in building an app, this would be overcome by the time and costs saved from staff repeatedly organising and teaching Joint School. Additionally, prehabilitation could be encouraged by providing animated instructions for pre-operative physiotherapy exercises as well as reminders to perform these exercises daily to improve patient compliance and adherence to these regimes. Exercise encouragement and prehabilitation has been specifically emphasised to improve post-operative outcomes51. Furthermore, supplementary features such as patient forums on the m-health app could provide comfort and mental preparation for the patient, whilst reminders could also be used to advise patients on medication and nutrition in the days leading up to surgery.
These proposed recommendations have been added to the process map for the ICHT orthopaedic pre-operative pathway in Figure 9 to give added perspective.
The elderly population and technology
A recurring problem identified throughout the TA and repeated in literature was digital illiteracy in the elderly population52-53. Considering the high average age (69 years) of elective orthopaedic patients, this could be seen as a major flaw of using technology in this space.
However, Deloitte research in 2018 shows 77% Smartphone penetration in the over 55 age group with technology penetration in this age group expected to further rise as it has over the past 6 years36. This makes mobile health and virtual care a promising opportunity for the older patient and their clinicians. In addition, nationwide programmes such as The One Digital programme by Age UK54 are demonstrating the success of working with the elderly to allow them to better engage with technology.
To promote adoption of innovation, it must be user-friendly, addressing the needs of the consumer and provide a tangible benefit to them55. Numerous studies have also shown that given convenience, perceived benefit and ease of engagement with the technology, the older demographic tend to adopt new technology in line with their younger counterparts56-58.
With the NHS suffering from a funding gap of £30 billion a year by 2020/215, costs are a significant barrier. Interviews emphasised that any solution must be cost effective with return on investment. Unless the new technology can recoup the original costs efficiently and require minimal maintenance, it is unlikely that the NHS would prioritise it.
The literature provides contrasting opinions on the cost-effectiveness of technology in general healthcare. A systematic review by Mistry et al59 demonstrated no conclusive evidence for the cost-effectiveness of telemedicine and telecare. However, more recent reviews by Delgoshaei et al60 and Michaud et al61 indicated cost savings associated with telemedicine in various medical fields. It must be noted, however, that there was a stark lack of research on the cost effectiveness of technological interventions in the pre-operative pathway.
A 2011 document from the Department of Health modelled a virtualized pre-operative assessment system, showing savings of £65.83 million simply by increasing efficiency in collecting data and reducing the number of cancellations62. This was at a Rough Order of Magnitude (ROM) cost of £1.7 million over 5 years, that included costs of infrastructure, development and technical support for 5 years62.
In addition to the possible financial benefits, technology enables more societal and indirect benefits such as decreased hospital stays, improved quality of life and decreased nursing and residential care by allowing patients to stay at home longer63.
Technology places the patient at the centre of their care, builds a platform for communication between the patient and the service and it enables pathway redesign by utilising the power of IT to re-engineer the outdated process.
Technology can help us deliver high value care as well as target the triple aim of healthcare: the simultaneous improvement of population health, improvement in patient experience of care and reduction in per capita cost64. It achieves these through improved lifestyle support and better outcomes across all patient groups, more personalised patient-centred care & journey, and more effective allocation of resources to low, medium and high-risk patients respectively64.