Introduction
NHS Direct is a national service founded in 1998 by the UK National Health Service ( NHS ) to supply a nurse-led 24-hour aid and advice service over the telephone. NHS Direct is a free service ( merely the local telephone call costs ) for the public presently having about 7.5 million calls a twelvemonth in England and Wales. In 2000, the UK Government introduced a program for future investing and reform within the NHS. At the bosom of these alterations was the desire to supply a wellness service built around patients ‘ demands, including the demand for cognition and information. Modern means of communicating, such as the Internet, have introduced new ways for accessing wellness services and information. As in other, particularly Western, states the figure of Internet users in UK is turning quickly. NHS Direct decided to widen its services to the Internet, presenting NHS Direct Online in 1999. The Web site offers information about unwellness, maintaining healthy, and how to entree local wellness services. One of the maps of this Web site is an e-mail online question service that offers more elaborate information on wellness issues, but does non accept questions from patients about specific symptoms. Although this limitation is clearly stated on the Web site, about a one-fourth of all on-line questions are about symptoms. This highlighted the demand for a more individualized, clinical problem-based service.
With this in head, NHS Direct Online developed a paradigm Clinical Enquiry Service ( CES ) offering a secure, confidential one-to-one Web-based audience with a nurse. It was thought that such a service might besides supply entree to wellness information and advice for clients whose demands are non presently met by the telephone NHS Direct service because of handiness jobs, e.g. the socially stray or those with hearing or address restrictions.
There are assorted Web sites offering chat room services for specific patient groups, such as malignant neoplastic disease patients or schizophrenia patients. A figure of Web sites have scheduled confab Sessionss where patients can inquire inquiries straight of a specialised doctor in the field. However, there are no services offering a one-to-one confab service with a medical professional.The pilot survey described here was set up to place the challenges and deductions of such a Web-based confab service. The purpose of this pilot survey was to research for CES the three most of import facets of any eHealth service or application: its safety, its feasibleness, and patient perceptual experiences of it.
Methods
Procedure And Participants
The six-day pilot was performed in an inner-city general pattern in Coventry ( England ) , an industrial metropolis. Non-urgent patients ( ie, those calling the pattern who did non bespeak an assignment that twenty-four hours ) were asked to take part in the survey. There were no other inclusion standards for the patients and their degree of computing machine literacy was non a factor. When patients arrived in the waiting room, a research worker gave them a short account of the survey and they were invited to take part and subscribe a consent signifier. The CES Web chat session took topographic point shortly after in an scrutiny room. A research worker was present to help the patient merely if he or she needed aid to continue with the CES audience, and to detect the patient ‘s behaviour and reactions. The patients could stay anon. during the Web confab, but, for a more personal attack, provided a first name for the nurse to utilize. The first measure in the confab was to except any pressing conditions by questioning the patient about the presence of thorax hurting, shortness of breath, etc.
Five NHS Direct-trained nurses based in Southampton were farther trained in the usage of Web confab. These nurses used the same NHS Clinical Assessment System ( NHS CAS ) , a triage determination support system bring forthing inquiries and advice based on patient replies, used in the telephone NHS Direct service. The CES Web chat application could non be implemented on the same computing machine as CAS, so the nurses had to utilize two computing machines during each Web confab session.
The possible triage end points generated by CAS, which correspond to the advice that NHS Direct nurses give patients, were:
- name 999 for an pressing ambulance
- visit the accident and exigency section every bit shortly as possible
- visit the accident and exigency section within 4 hours
- reach your GP within 4, 12, or 36 hours or within 2 hebdomads
- place attention.
Immediately after take parting in the CES Web confab session, all patients were seen by a GP at the same pattern. The patients were instructed non to discourse the Web chat or the suggested terminal point with this physician. A system director was present at the pattern to work out proficient jobs if they arose.
The Web Chat Application
A Web chat application service was leased from Instant Service USA and was made accessible merely to the nurses and patients take parting in the pilot. The interface to the service was tailored to our demands. Prior to each Web confab session, patients filled out several online signifiers about their general wellness. The Web confab was between patient and nurse, and the treatment was non shared with anyone else. A log file of each session was stored on a secure waiter.
Evaluation Of Safety
One of the most of import facets of any invention in wellness attention is its safety. Prior to developing any telemedicine or eHealth service, it is of import to make up one’s mind precisely who the intended users are. It is every bit of import to make up one’s mind who should non utilize the service ( eg, really ill patients ) , and to prove the service ‘s ability to observe these patients to guarantee its safe operation. In add-on, we should look into whether the service may harm eligible users included in the pilot survey. In this pilot survey, the safety of the Web confab was evaluated on two degrees: the ability of the NHS CAS-assisted nurse to observe pressing instances, and understanding between the CES end point and the GP end point. After every audience, and with the benefit of a full audience, the GP recorded the advice he or she would hold given to the patient if the patient had phoned the GP that twenty-four hours before go toing, utilizing the same list of possible end points as the Web confab nurse. For each patient, we compared the end point allocated by the GP with the end point allocated by the nurse at the terminal of the CES session. To formalize the GP terminal point, the GPs besides provided a list of intercessions performed on all patients collected from the patient records, and patient results after a 3-month followup.
Evaluation Of Feasibility
The rating of feasibleness demands to include a cheque that that the resources required are likely to be available and that the engineering has equal coverage and some promise of cost-effectiveness. One of the common jobs of telemedicine or eHealth applications is that they frequently involve non merely expensive engineering ( video-conferencing tools, digital cameras, fast Internet connexions ) , but besides important clip, preparation, and alterations in work pattern for health-care professionals ( 8 ) ] . We explored the general feasibleness of CES by concentrating on the scope of possible CES users, the resources needed to run the service, and the quality of interpersonal communicating. For all patients, age, gender, and self-reported computing machine literacy were recorded. In order to cipher the continuance of the Web confab and its constituents, the intervals between specific defined events happening during a CES session were logged into a file.
We compared the entire continuance of the Web confab session with the average continuance of NHS Direct telephone audiences for patients naming with the same symptom. For each presenting symptom, the average call continuance of a random sample of 30 instances with the same symptoms was calculated by NHS Direct.
Since communicating utilizing Web confab consists merely of exchange of typed text, we explored whether this was plenty to set up a sufficient degree of resonance between the nurse and patient. Patients were interviewed about this, and the log files were used to recover any nurse inquiries for which the patient response indicated a demand for elucidation or rewording.
Evaluation Of Patient Perceptions
Patient perceptual experiences about a assortment of issues were checked utilizing three instruments. The Telemedicine Perception Questionnaire ( TMPQ ) , a validated questionnaire designed by the University of Minnesota, was used to mensurate the alteration in patient perceptual experience of CES after utilizing it. The questionnaire was adapted to our survey with permission by little rewording ( altering “ place telecare ” into “ CES ” or “ Web confab ” ) or excepting some inquiries ( eg, those about costs ) . The users scored each point twice: before and after utilizing CES, with each mark runing from 1 ( strongly disagree ) to 5 ( strongly agree ) . The highest possible mark with our modified TMPQ was 60. Some points were negatively worded, so scores for these points were transformed ( eg, a mark of 5 was transformed into 1 ) during the analysis, so that higher tonss ever represent positive patient attitudes toward CES. A mated sample t-test was used to look into for differences between the pre- and post- trial tonss. We besides used a 2nd, researcher-administrated, instrument incorporating 23 unfastened and closed inquiries to capture patient remarks and experiences with CES. Finally, all patients were observed by a research worker to analyze their behavior and log uncovering remarks spontaneously made by the patients during the Web confab.
Data analysis was performed utilizing SPSS 10.1.
Consequences
Safety
The nurses were instructed to inquire several inquiries in order to except any possibility of an pressing job. However, the patient could hold shown marks of urgency without the nurse reacting to them. The log file analysis showed that the nurse responded to every patient remark or inquiry. This was partly enforced by the Web confab application, as the nurse could see when the patient was typing, which prevented the nurse and patient typewriting at the same clip.
The GP audience resulted in 13 patients having advice merely, 13 a prescription, three probes, two referrals and one a medical certification. Eight patients received multiple intercessions. More than half ( 57 % ) the patients did non travel back to their GP for the job, and 30 % ( 7/23 ) returned merely one time during the three-month follow-up period. Three patients ( 13 % ) returned more times ( three, four, and eight times ) to their GP for the undermentioned jobs: urinary frequence, thorax hurting after taking medical specialty for acerb dyspepsia, and carcinoma of the prostate.
We found an exact lucifer between the CES end point and the end point defined by the GP in 45 % ( 10/22 ) of patients ( Kappa ( IA? ) =0.25 ; 95 % assurance interval 0.37 to 0.45, which is low ) . Where there was a difference in end points, in most instances the CES nurse suggested a more pressing followup than the GP ( 45 % ; 10/22 ) . With merely two patients did the CES nurse propose a less pressing audience. These two patients attended their GP for ague lumbar back hurting and fatigue.
Feasibility
During the pilot, 25 patients agreed to take part. Two patients were excluded from farther analysis as they were members of the pattern staff. More than half ( 57 % , 13/23 ) of the patients were female. Patients varied in age ( range 19-80, mean 48 old ages ) , educational background, and business. Although 78 % ( 18/23 ) of patients considered themselves computing machine literate, merely 64 % ( 14/22 ) reported good typewriting abilities. Not all patients were experient Personal computer users, but 87 % ( 20/23 ) found it easy to depict their symptoms on the Web, and 96 % ( 22/23 ) stated that CES offered sufficient resonance with the nurse. No patient asked for a elucidation of any of the inquiries asked by the nurse.
The Web chat connexion with the nurse was disconnected four times in 25 audiences, but each clip was easy re-established.
The average continuance of the Web confab Sessionss was 30 proceedingss [ 25th percentile 23, 75th percentile 36 proceedingss ] . This was more than twice every bit long as for a similar group of patients utilizing the telephone NHS Direct services. There was a positive correlativity between patient age and entire continuance of Web chat ( rs=0.44, p=0.04 ( 2-tailed ) ) .
About all patients ( 96 % , 21/22 ) were happy about the clip that the Web chat took to finish. One patient disconnected himself after 10 proceedingss as the Web chat took longer than he expected and a proficient job occurred.
Turning to the constituents of the CES audience, the first portion of each session was exclusion of any pressing conditions and this took a median of 9 proceedingss [ 25th percentile 6, 75th percentile 11 proceedingss ] . This procedure besides included replying several inquiries on a Web signifier prior to the Web confab. The average continuance of treatment about the patient ‘s current job was 18 proceedingss [ 25th percentile 9, 75th percentile 25 proceedingss ] .
Patient Percepts
The highest mean mark ( 3.9 ) in the TMPQ pre-test was for patients estimation of the ability of nurses to obtain a good apprehension of their wellness job over the Internet ; the lowest was 3.2 for concern about the deficiency of face-to-face contact. The most positive sentiment following experience with CES was for CES as an add-on to regular attention ( 4.3 ) . A mated sample t-test was performed with 20 instances, as one pre-test reply and two post-test replies were losing. The analysis showed significantly higher average post-test tonss compared to pre-test tonss ( intend pre score 44/60, mean station 49/60, paired sample t-test: p=0.008 ( 2-tailed ) , score difference 5, ( 95 % CI 7.4-1.3 ) ) . It is improbable that the losing informations would significantly change the mean mark for these points. Patient perceptual experiences improved for all points after utilizing the CES Web confab, but this betterment was important for merely two points, approximately CES going a standard manner of wellness appraisal in the hereafter and CES doing it easier to reach NHS Direct.
The entire TMPQ mark per single patient decreased after utilizing CES for four patients ( runing from 7 to 1 points less than in pre-test, average autumn 3.8 ) and increased for 15 patients ( runing from 1 to 18 points more than in pre-test, average rise 6.8 ) . One patient did non alter her sentiment about CES after utilizing it. No correlativity was found between patient age or gender and perceptual experience about CES measured utilizing TMPQ.
Discussion
The consequences of this pilot suggest that the CES nurse-led Web chat service might be safe as a triage system for non-urgent patients. This safety facet is supported by the fact that CES nurses suggested a more pressing followup than the GP for the same symptoms in about half of the instances. However, patients who participated in this pilot survey were non typical users of CES, as they had already made a determination to see their GP. Although a general pattern as survey scene is a safe and practical environment for the first pilot survey, farther surveies should be performed in a place or workplace scene where the service would really be used by the populace. CES was designed to for members of the populace who are difficult to make by other agencies of communicating. In this first pilot, we did non show the service to this group of users.
Exclusion of pressing patients is one of the of import functionalities of CES. Because we did non include pressing patients in our survey, we are non able to judge whether CES would be a safe and dependable service in a existent life state of affairs.
As all communicating between the nurse and patient is based on typed text, marks of emotion and empathy are difficult to pass on. Therefore, it is possible that some replies given by patients, and some inquiries asked by nurses, might be interpreted otherwise than expected. Another menace of such indirect communicating is the possibility that patients might give untrue information ( eg, incorrect inside informations of their age, sex, badness of symptoms, or geographical location ) that can non be checked by the nurse.
Patients with a broad scope of age, gender, and computing machine experience were able to explicate their symptoms utilizing Web confab and to set up an equal degree of communicating with the CES nurse. The Web confab of older patients lasted longer than that of younger patients. It is hard to find for which age this difference is important as we had little samples from each age group. This difference might be due to the patients ‘ velocity of typing. Since we did non win in happening a similar survey researching one-to-one Web confab between a patient and wellness professional, we compared the continuance of CES triage with the continuance of telephone triage. In general, CES Web chat took twice every bit much of the nurse ‘s clip as NHS Direct telephone triage and this was considered unacceptable from the fiscal point of position. However, we believe that this job is partially due to an inefficient information direction system ( eg, CAS and CES were running on two different computing machines ) and time-consuming processs, such as exclusion of exigency conditions by the nurse. Most patients did non hold jobs with the continuance of a CES session.
Although CES would be excessively expensive as a service unfastened to any UK patient in the same manner as NHS Direct, it might be helpful for certain groups of patients, such as those who wish to discourse private jobs ( eg, sexually transmitted diseases, HIV, psychological jobs, dependence ) , particularly where they can be overheard, such as at work or at place, and for people with address jobs ( eg, those who are deaf, diffident, have dysphasia or other types of address troubles ) .
The TMPQ is a validated instrument, but it underwent some accommodations before utilizing in the pilot and was non re-validated. In farther surveies, this altered questionnaire should be re-validated. Nevertheless, patients were positive about the potency of a Web chat version of NHS Direct and became even more positive after seeking out the service, independent of their age and gender. After utilizing CES, some patients stated that this service will go a standard manner of wellness appraisal in the hereafter. However, as NHS Direct Online intended, most patients considered CES an add-on to regular attention, non a replacing for it. Privacy issues did non look to be a job for the patients included in our survey. A important betterment in patient perceptual experience was found about the easiness of utilizing CES to reach NHS Direct. The patients were more positive about the service after holding tried it out. The engineering became less “ chilling ” after utilizing the service, and patients started to acknowledge the advantage of CES over the telephone service. Several patients volunteered fresh benefits of the Web chat medium over the telephone NHS Direct service, such as the ability to re-read the nurse ‘s replies and holding more clip to believe about her inquiries before reacting. An 80-year old patient described these advantages as follows:
… When you go to a physician, you forget things because you ‘re a small spot nervous. You forget what you ‘ve said, to state what you wanted to state and what has been said by the physician. Using this service you have more clip to believe and inquire anything you want, you can see what you and the nurse said, that is much better…
Decisions
This survey was performed to research whether the pilot CES service was sufficiently safe, executable, and acceptable to patients to warrant a larger survey. We can reason that CES was sufficiently safe in the pilot stage, but in order to do farther judgements about safety, more proving with pressing instances should be performed. At this phase, farther development on the CES service has been postponed because of the long continuance of conversation between the patient and nurse, and other NHS Direct Online precedences. The pilot resulted in several recommendations about how to better the package and diminish the communicating clip. Communicating with patients through the Internet should foremost be farther explored in more closed, controlled scenes, such as GP patterns or wellness Centres, before this service is offered to the populace at big. However, it is likely that commercial companies will develop and offer such services before scientific surveies are performed. Therefore, we believe that early pilots such as ours, researching safety, feasibleness, and acceptableness, are of import to foretell the hazards and benefits of eHealth applications such as CES.
Recognitions
We thank NHS Direct for funding this survey. Particular thanks to the patients and staff at The Crossley Practice and to Alison Harding and Steve Clarke for their important part to this survey. We acknowledge the generousness of George Demiris, Stuart Speedie, and Professor Stan Finkelstein in leting us to do usage of the TMPQ instrument. Finally, we thank the CES nurses, Fran Campbell, Ollie Watts, Craig Murray, Nicky Lackford, and Jodie Adams.
Conflicts Of Interest
AM Tarpey and G Murray were employed by NHS Direct Online during the design and rating of NHS CES.
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