What is the acceptability of real time 1:1 videoconferencing between clinicians and patients for a follow-up consultation for multi-directional shoulder instability?

Abstract

Background

The use of real time 1:1 videoconferencing is growing in popularity in clinical practice. Authors have explored the effectiveness and acceptability of videoconferencing for patients; however, little research exists on the viewpoints of clinicians.

Methods

Patients with atraumatic shoulder instability attending a tertiary treatment centre were offered the choice of videoconferencing or a face-to-face consultation for their follow-up session. Immediately after the consultation a semi-structured interview was conducted to explore the underlying reasons behind its use and acceptability.

Results

All clinicians found the use of videoconferencing acceptable provided the patients were aware of its benefits and limitations. Of the 13 patients included in this study, seven chose to undergo a videoconferencing consultation. It was acceptable provided the clinical practice could be modified to achieve the objectives of the consultation. The use of videoconferencing required access to a quiet room with the appropriate technology.

Conclusion

Videoconferencing is not acceptable to all. Benefits included not having to travel and the opportunity to assess and treat patients in their home environment. The use of videoconferencing did not allow for ‘hands-on’ assessment which was important for less experienced clinicians.

Introduction

We have an ageing population frequently affected by life-limiting conditions, often of musculoskeletal origin. Specialist orthopaedic care is required but accessing such care can be challenging. One possible way to access this care is through using real time 1:1 videoconferencing (VC), which has a long history in medicine. Over recent years, large-scale studies^1,2 have shown VC to be safe and effective at delivering healthcare when compared to normal face-to-face practice. VC software is now widely available for consumers to use on compatible devices such as personal mobile phones, tablets or laptops and have displaced the expensive, complex and often unworkable bespoke hardware and software that dominated early telemedicine demonstrators.³ These allow for the potential of VC to be realised in a clinical setting at minimal cost.

The role of VC in physiotherapy practice, which often requires hands-on treatment and assessment, is yet to be determined. There are examples of remote video assessment of shoulder disorders being consistent and reliable with conventional methods⁴ and positive clinical outcomes with video-based rehabilitation.⁵

A systematic review⁶ found the use of VC to be both feasible in clinical practice and acceptable to the patients after total hip and knee joint arthroplasty,⁷ knee replacement⁸ and shoulder replacement.⁹ No studies in this review were identified on the acceptability of VC for clinicians.

Numerous telemedicine and telecare studies have now been reported using the ‘Skype’ application,¹⁰ but the main focus has been the management of long-term conditions such as diabetes or heart failure.¹¹ No projects were identified on the use of Skype in the management of musculoskeletal problems in a snapshot review of the literature published in 2015.¹⁰

In this paper, we describe an exploratory study that sought to understand the factors that contribute to the acceptability of VC using Skype for orthopaedic patients and rehabilitation professionals. We focused on patients undergoing follow-up consultations after inpatient rehabilitation for atraumatic shoulder instability, and we were concerned with factors that might promote or inhibit its embedding in everyday clinical service provision. This patient group often requires ongoing follow-up at a national specialist hospital and VC has been identified as a means to reduce the burden on these patients. Although aforementioned research has been conducted in the area of shoulder disorders, it was thought that the complexities of atraumatic shoulder instability required further investigation prior to the introduction of a VC-supported service.

This work was informed by normalisation process theory (NPT).¹⁰ NPT focuses on the work of being a patient or rehabilitation professional and considers how changes in this work interact with ideas about acceptability and feasibility. An assumed level of acceptance is given to VC by patients and clinicians who choose to use VC. This paper specifically focuses on the work of introducing a new consultation format and the underlying reasons behind its use and acceptability. This research paper addresses research question: What is the acceptability of VC between clinicians and patients for a follow-up consultation for atraumatic shoulder instability?

Materials and methods

Setting

At a specialist hospital, patients with atraumatic shoulder instability, which results in recurrent and usually disabling dislocation, are admitted for a two-week intensive rehabilitation programme. The programme is in place to support patients who have disability associated with atraumatic shoulder instability and has a particular focus on the management of shoulder dislocations.

Patients

All patients admitted to this shoulder rehabilitation programme, over a three-month period, were invited to participate in this study provided they met the inclusion criteria (shown in Supplementary Material). Patients were provided with an information sheet and given 24 h to consider the information and ask the researcher questions about the study. Informed written consent was then taken. As per routine practice all patients, on entering the rehabilitation programme, were allocated a treating physiotherapist and occupational therapist. Patients were included in the study regardless of pain levels, previous physiotherapy and occupational therapy experience and disability. Patients recruited to the study were offered the choice about whether the six-week consultation would be face to face, involving travelling to the specialist hospital, or via a remote consultation (Figure 1).

Figure 1.

Normal patient pathway and research pathway. VC: videoconferencing.

Clinicians

Physiotherapists and occupational therapists, working at the specialist hospital, were invited to participate in the study. The members of staff were clinicians specialising in the management of atraumatic shoulder instability or on a senior musculoskeletal rotation. Patients, regardless of whether they opted for a face-to-face or VC follow-up, were seen by their treating clinicians at the six-week follow-up.

Face-to-face consultation (usual practice)

Six weeks after the rehabilitation programme patients are reassessed to review progress and make recommendations for ongoing management. The objectives of the face-to-face consultation, as is usual practice, are to review outcomes and to progress onwards from the rehabilitation programme. The objective assessment would generally consist of observation of gross range of movement and movement patterns and functional tasks. Manual muscle testing would occasionally be required for shoulder muscles.

VC

The objectives of the VC consultation were the same as normal practice – to review outcomes and to progress onwards from the rehabilitation programme. The VC was conducted using Skype. The researcher (AWG) provided training for patients if they felt this was necessary. AWG offered the choice of a ‘dummy run’ consultation approximately one week before the clinical consultation for all patients who chose to use Skype. Prior to the clinical consultation AG set up the clinicians’ computer, in a private room, and established the Skype connection with the patient prior to the clinicians’ arrival. The clinical consultation was conducted with the clinicians (physiotherapist and occupational therapist) and the patient, without the researcher present.

Qualitative interviews

A semi-structured interview was conducted with each study participant (patients and clinicians). Patients undertook the interview immediately after the follow-up consultation (via VC or face to face – dependent on the patient’s choice of consultation format). Clinicians undertook their face-to-face interview at the end of the study period due to diary scheduling. Interviews were audio recorded. The same interview structure was used for all interviews with a slight variation on the wording to make them clinician or patient appropriate for each respective group. The interview structure was based on the constructs of NPT and can be viewed in Supplementary Material.

Qualitative data analysis

Interviews were transcribed verbatim and inputted into a computer-assisted qualitative data analysis software programme (QSR NVIVO software – version 10). A directed content analysis¹² was undertaken analysing the factors in accord with NPT.¹³ All transcripts were read by two researchers (AWG and CRM) and both coded the data independently. Coding of data was undertaken using a previously published NPT coding framework¹³ to guide the process and data were coded to each of the subconstructs of NPT. Data were organised within the constructs of NPT (Capability, Capacity, Potential, Contribution – Supplementary Material) and illustrated with verbatim extracts from the transcripts. Data coding and analysis was reviewed by these researchers to ensure validity of the coding. A third researcher (AJ) was available to resolve any disagreements. The purpose of this study was not to extend the framework beyond NPT and therefore results are presented in accord with the theory.

Ethics

Local R&D and ethical approval was obtained from the London-Stanmore Research Ethics Committee (Ref: 15/LO/0513), and written informed consent was provided by all participants prior to interview. A Privacy Impact Assessment was carried out in accord with specialist hospital’s Information Governance guidelines. All data were link anonymised.

Results

Sixteen patients and nine clinicians were invited to join the study. One patient was subsequently deemed to require surgical intervention and was transferred off the shoulder rehabilitation programme pathway and was thus removed from the study. One patient declined all forms of follow-up and another patient was unavailable for interview during the time frame for this investigation. All were removed from the study. One clinician was unavailable for interview and was also removed.

Of the 13 patients entering into the study, seven opted for a VC and six opted for a face-to-face consultation. Patient demographics are shown in Table 1. Patients were admitted to the specialist hospital for rehabilitation of their shoulders following a diagnosis of atraumatic shoulder instability. All patients experienced difficulties with the management of their dislocations and functional tasks and had experienced physiotherapy prior to being admitted for rehabilitation. Comparison between the VC and face-to-face groups and patient demographics was not undertaken as the focus of this study was on the acceptability of the VC consultation.

Table 1.

Patient demographics.

	VC group (n = 7)	Face-to-face group (n = 6)
Median age (min–max)	22 (21–35)	21 (19–24)
Median distance living from the hospital (min–max)	114 mile (74–170)	169 mile (45–438)
Method of using Skype	Smartphone = 1 Laptop/desktop = 6
Place using Skype	Workplace = 1 Home = 6

VC: videoconferencing.

Eight clinicians were interviewed (five physiotherapists, three occupational therapists). Seven clinicians specialised in the management of atraumatic shoulder instability and were permanent members of the team. One physiotherapist was a senior musculoskeletal rotational member of staff and had been based on the team for three months prior to commencing the study. The median length of interview was 25 min (13–52 min). Data saturation was obtained for all constructs relating to NPT. This was defined as no new knowledge being generated from interviews and relates to both patient and clinician interviews.

Directed content analysis of qualitative data using NPT¹⁰

Capability – Possibilities presented by a VC consultation

The VC was seen as successful when the consultation objectives were achieved. Clinicians were able to progress exercises, advise and problem solve over VC. This worked well when the patients were already known to the clinicians: ‘You can generally achieve that well, a successful one [VC consultation], as long as you can have that rapport and see each other and interact with each other’ (Clinician 2 = C2). VC was useful for measuring gross range of movement but was limited when hands-on treatment was required. This practical aspect of follow-up was important to all patients who chose to not use VC. One patient felt not receiving hands-on intervention was an issue and reported a preference to travel in for their treatment: ‘Even though the travel is such a pain, and it’s so awful, I would rather have the travel and see someone than not if you know what I mean’ (Patient 10 = P10, ff = face-to-face patient). VC required patients to make modifications to their environment to demonstrate exercises. This involved adjusting the VC equipment to enable the other party to observe. This was the case for all patients, regardless of device used.

Using VC offered unique opportunities to enhance the scope of the consultation through assessing the patient in their own environment:

you do start to realise that is a patient is sat in their kitchen having a consultation if they just swivel their screen round and they can show you what they are having difficulty with, they can show you the cupboard they can’t reach or what particular action they can’t do in their environment… that opens up another whole dimension. [C1]

Clinicians ultimately felt comfortable offering patients the choice of a face-to-face or a VC consultation. It was felt that patients would need to understand the limitations of using VC versus face to face. In circumstances where practical assessment was thought to be essential, patients would be encouraged to travel to the hospital to allow for assessment. In circumstances where a patient could not travel to the hospital, VC was seen as superior to a telephone call or missing the appointment.

Contribution – What patients and clinicians do to implement VC

In this study, the researcher established the connection with the patients prior to the arrival of the clinician. During the research a ‘dummy run’ was offered for patients before the follow-up who chose to use VC and this was seen as useful:

So I think if you had a proper sit down and talk about it then maybe it would like, consider the patients doing it. Because if you like you know you said like last time like ‘oh at your next appointment we could run through it’ but because the patient would probably forget it. But if you sit down properly and spoke about it there and then, if you had the time of course, I think you would probably go for it. (P2, ff)

VC could be used to assess gross range of movement and to observe exercises but it was not thought to be as effective for this as a face-to-face meeting. Patients need to understand these limitations in order to make an informed decision on its use. Making sense of the benefits and limitations of VC was essential in determining its acceptability and one patient felt that the lack of physical touch with VC was a reason for not wanting to use it: ‘my problems aren’t visual, they are inside. You need to understand what muscles are moving, I’ve got a very active pectoral muscle and I don’t think you would be able to see that over VC’ (P10, ff). Less experienced clinicians found that they had an increased reliance on their hands when assessing patients:

As a junior member of the team I can’t pick up so easily if someone is anteriorly, or subluxed posteriorly, I have to be hands on and look at people in lots of different angles or positions, whereas maybe if you are more senior you can do that easily from eyeballing somebody. (C4)

Capacity – Social structural resources available to agents

Patients using VC felt the intervention did not affect the patient and clinician relationship and found that it was no different from their experience of coming in for a face-to-face appointment:

It just felt like I was talking to them as if they were in the room. I don’t feel that because it was to a screen it was any different. I could still say what I wanted to say and I could hear what they were saying. (P15, VC = VC patient)

One patient did not however feel comfortable with the thought of a consultation over VC: ‘It would be really weird and detached. I like face to face interaction I don’t like screens around me all the time I think it would create a bit of a detached sort of relationship…’ (P8, ff). Patients reported feeling more relaxed having the consultation in their own surroundings rather than in a hospital environment:

I think being in this sort of environment at home you are not too concerned with laughing because you could distract someone else doing their physio so here is like, you know I’m doing my physio in front of them, we are still having a laugh and chatting and we don’t need to worry about disturbing anybody else. (P13, VC patient)

One clinician expressed concern at the threat of distractions having a clinical consultation in a non-clinical environment:

the patient said oh it doesn’t matter when it is, “I can just go into the work staff room and I can VC you there in my lunch break” … is it too flexible, if they are booking appointments in their lunch break to be in the right place mentally to think about themselves and their exercises. (C4)

Although the concept of not having to travel to access the services at the hospital was popular with all patients, some patients declined this option because they did not know how to use VC: ‘I would want to see how it works before doing it… ooooh… kind of a trial run? Or to see someone else doing it? Or something like that?’ (P10, ff). Patients and clinicians need to have access and understand how the equipment worked. All of the clinicians interviewed in this study emphasised the importance of having access to an appropriate room available to use VC.

Potential – Social cognitive resources available to agents

Clinicians see a face-to-face follow-up as the ‘gold standard’ but there was awareness that VC might be preferable to patients. Clinicians distinguished when a face to face would be required:

I think they were two different patients, one of the patients we actually after thought her next review has to be face to face because she had been having some more challenges whereas the other patient had to come back to clinic and a Skype review was perfect it was a waste of time her coming down. (C7)

Not travelling to the hospital had benefits: saving journey time, saving money and reducing pain from travel. Pain reduction was often the motivation for patients to opt for VC. Patients often presented in an improved physical state as a result of not travelling and clinicians recommended VC for patients who found travel particularly challenging.

It saves me having to come to London so that is the biggest thing. Also, I can’t travel on my own and I need someone to help me, so it saves someone I know having to take the day off work to come all the way over with me. At least I can do this on my own. (P3, VC)

Discussion

NPT¹³ has been used in this paper to outline the work of introducing VC. The use of VC was acceptable to those patients and clinicians who chose to use it and this study explores the reasons behind its acceptability. This study emphasises that for VC to be acceptable to clinicians, the VC consultation must be able to provide the information that is needed which may require alteration of the examination. In a study where patients were followed up by VC after primary hip or knee arthroplasty,¹⁴ it was considered that an evaluation could be based on a questionnaire and consideration of locally performed radiographs. In the current study, assessment by passive movement was deemed not to be essential; however, in other situations of orthopaedic practice, this may be necessary and might hinder the uptake of VC in practice.

The infrastructure needs to be in place for remote consultations to work efficiently. Recent advances in personal devices and software, freely available to download,¹⁵ have allowed for the potential of VC. The challenge remains for those populations with a lack of familiarity with this equipment, such as the elderly population, and those with a poor socio-economic status who cannot access the equipment.

A major factor determining whether patients thought VC would be acceptable was their perception of whether or not this remote consultation would interfere with the patient–clinician relationship. In general, those patients who thought it would interfere elected not to have this form of follow-up. Those patients who elected to have VC were all satisfied that this form of follow-up did not interfere with their patient–clinician relationship.

It has long been recognised that patient satisfaction^16,17 and acceptability¹⁸ is important for the uptake of telemedicine in clinical practice. In this study, the use of VC was not acceptable to some and these patients opted to travel to hospital. Some, however, reported they would be happy to use VC under different conditions. It was clear from this research that the acceptability of this new consultation format is multifactorial and warrants further investigation. To our knowledge, there is no research focusing on the role of patient and clinician preferences behind the use of VC and further research in this area may assist with further implementation of VC in clinical practice.

Within this study it was found that clinicians were fully committed to trialling VC. Consideration must go to the fact that two of the authors (AWG and AJ) are also clinicians within the department and this may have influenced clinician engagement. The interview schedule and analysis was designed using NPT. The use of supplementary theoretical models or a combination of open and directed content analysis might have gleaned additional data which could have informed the results. Although no new information was generated from the interviews we conducted, a larger sample size may have gleaned more information from the viewpoints of this patient group. A larger sample size and quantitative data may have provided a more precise estimate of the numbers of patients who may choose to use VC.

It must be appreciated that within a tertiary setting the clinicians felt that VC would benefit patients who travelled from a long way. Anecdotally within this study it was not immediately obvious that patients underwent a VC consultation due to the distance they had to travel. It became clear, however, that the benefits for VC went beyond the perceived convenience of not having to travel and the use of VC enhanced the consultation through assessment in the patient’s home environment.

Conclusion

This study illustrates that half of patients interviewed preferred to have a face-to-face consultation rather than VC. This was because of lack of familiarity with the technology or concerns over the impact of VC on the relationship between the therapist and patient and wanting ‘hands-on’ assessment or treatment from the therapist. VC may be useful for experienced clinicians who have confidence and experience with assessment with the presentation to be treated. VC may be less useful in situations where patients had not met the clinician before. For patients who elected to have VC, in all cases their experience was deemed to be positive. To introduce VC as a standard practice, both the therapist and the patient must be convinced that this form of consultation is fit for purpose and is in the patient’s interest. Appropriate devices and applications must be available. The fact that VC obviates the need for travelling may be a particular benefit for national referral centres where patients are referred from long distances – although this was not an obvious factor, in the patient’s choice, in this study. Therapists identified the need for dedicated time and space to conduct VC. This study is likely to be relevant to other forms of follow-up consultation in an orthopaedic setting. It is clear that VC is not acceptable for all and further research exploring how VC may be integrated in other stages of the patient pathway and patient and clinician preferences surrounding its use would be of value.

Declaration of Conflicting Interests

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Funding

This research was funded by the National Institute for Health Research Masters in Clinical Research Fellowship, hosted by the University of Southampton.

Ethical review and Patient Consent

Local R&D and Ethical approval was obtained from the London-Stanmore Research Ethics Committee (Ref: 15/LO/0513). Patients included in the study were provided with an information sheet and given 24 h to consider the information and ask the researcher questions about the study. Informed written consent was then taken.

Supplementary material

Supplementary material is available at: http://journals.sagepub.com/doi/suppl/10.1177/1758573218796815.