Implementation of a web-based asynchronous consultation service in a hospital in Northeast Scotland: a multi-method multi-lens assessment

Background
‘Asynchronous’ (at different times) patient-to-provider communication has the potential to improve care access. It has mostly been tested in primary care but is increasingly used in outpatient care, particularly for highly visual conditions such as dermatology. NHS Grampian decided to roll out an outpatient asynchronous consultation system from dermatology to two additional outpatient care clinics—pain and gastroenterology—as part of its COVID-19 recovery strategy. We designed a multi-method study including staff, patient, and public perspectives and quantitative data from the NHS to obtain a rounded picture of innovation as it happened.
Methods
This study was conducted between April 2021 and September 2022 in Aberdeen Royal Infirmary (a large teaching hospital in Northeast Scotland). The study comprised: 1) NHS service evaluation: patient satisfaction survey, and service usage data routinely collected between January and September 2022; and 2) qualitative study: three online and one face-to-face public focus groups concerning public readiness for the new service and semi-structured interviews with staff and patients about their experiences with designing, implementing, and receiving the new service. The qualitative study involved three population groups: 22 people who might be at risk of digital exclusion and those who support them; 14 clinical, administrative, technical and project management staff involved in system adoption; and 6 patients who completed or did not attend asynchronous appointments. Data from a patient satisfaction survey were analysed descriptively. Routine data analysis included comparisons across users’ demographics, the acceptability of the service to users across pathways, non-attendance rates, and appointment outcomes. The Socioeconomic Deprivation Index served as the proxy for understanding health inequalities. Individual interviews and focus group discussion transcripts were analysed thematically.
Results
Responses from the public and patients were largely positive about asynchronous consultations in outpatient care. Only 18% of survey participants were explicitly unhappy that they received an invitation to the service. Staff noted differences in uptake between specialities, where the new system was thought to work better for pain self-management because it fitted well with current processes. To varying degrees, potential and actual users of the system— patients, public and staff —recognised its potential usefulness as an NHS service. Potential benefits regarding access, convenience, reduced travel and waiting time, better information gathering/sharing and more flexibility for clinicians were noted. Participants aired concerns that it might not be preferred or work for some people (especially those lacking digital skills or struggling to express themselves in writing), suggesting a need for informed choice and flexibility. The NHS service evaluation found no evidence that those from the most deprived communities were less likely to accept asynchronous consultations, receive treatment or be offered open returns. One universally acknowledged opportunity to improve the system was to increase patient acceptance through better communication (including better use of language around what is meant by ‘appointment’).
Staff expected a straightforward technical system transfer from dermatology to other receptive specialities, but despite a favourable context and organisational support, the reality has proven complex. Despite obstacles and shortcomings, the system's deployment across two specialities was seen as a success. Sustainability was linked to funds to afford allocated time for clinicians, operational staff, a clinic coordinator, a project manager, an evaluation lead, and the eHealth team.
Implications
Asynchronous patient-doctor communication offers a viable alternative to more traditional forms of communication also for less visual conditions. This study can inform practical strategies for supporting staff in implementing asynchronous consultations (e.g., managing expectations about the non-linear nature of the process, working around task issues, and maintaining continuity of communication). For potential patients, careful technical support and explanation are needed, as well as a choice of consultation routes, to ensure digital inclusion.