Digital health in primary care: risks and recommendations

Consultation skills

Telephone consultations (TCs) were initially introduced to meet increased patient demand to speak to a doctor. As early as 1978 TCs were described as being as much a part of a doctor’s equipment as a stethoscope, and are now commonplace.¹ Video consultations (VCs) incorporate visual elements lacking in TCs. Studies confirm that clinicians value VCs as they allow them to pick up non-verbal cues, and patients describe greater confidence in VCs compared with TCs.² However, compared with face-to-face consultations, both TCs and VCs tend to be shorter, with lower exchange of information between the patient and physician.³ Safety of remote consulting remains unclear as physical examination is not possible and subtle signs may be missed.⁴ The recent COVID-19 pandemic has resulted in rapid widespread adoption of remote consultations (TC and VC) in general practice in the UK (Box 1) with many healthcare providers conducting the vast majority of interactions with patients remotely.

Currently, communication skills training takes place almost exclusively in face-to-face formats, thus not reflecting the reality of increasingly digital practice. Communication skills training in undergraduate education and beyond should incorporate digital interfaces, emphasising strategies for effective, safe communication.

Access vs. workload

The NHS Long Term Plan describes a ‘digital first’ approach where technology will supplement face-to-face models of care, improving efficiency and quality.⁵ However, the ability of digital health technologies to control demand for face-to-face primary care contact and healthcare costs remains unclear.⁴ Studies suggest that non-face-to-face (electronic) consultations may actually increase demand for urgent face-to-face consultations.^6,7

New ways of interacting digitally with patients include through remote consultations, email, and text messaging. This new way of working requires GPs to self-direct, manage workflow, and understand where and how to set boundaries around continual patient access. Training should thus emphasise how to manage digital workflow.

Safety/effectiveness

The growing number of apps and new technologies for health care are easily accessible to patients, but often lack clear regulation, robust evidence base, and evaluation.^8,9 Furthermore, reviewing and appraising the ever increasing number of healthcare technologies is likely to be beyond the remit of the NHS.⁸ There is a rapid increase in use of wearable devices allowing clinical observations. While in theory these are powerful tools for identification of important abnormalities in asymptomatic patients and self-monitoring of various medical conditions, accuracy and need for calibration are often unclear, leaving patients and clinicians unsure how reliable readings are.

Despite potential risks, the King’s Fund describe how ‘technology-supported self-management can help to empower patients to better manage and understand their condition, supporting improved behavioural and clinical outcomes’.¹⁰

Primary care professionals need training on critically appraising safety and effectiveness of new technologies including basic guidelines. Training is needed in interpretation of app-derived data and how to discuss this data with patients. Patients should also be supported in choosing between apps and technologies on offer.

Ethics

As digital technology use in health care has grown, so have concerns around privacy, confidentially, transparency, data ownership, sharing, and storage. For example, for the NHS care data programme, patient data was shared for not only research purposes but also with businesses for commercial exploitation.¹¹

Regulators have raised safeguarding concerns in relation to digital technology because of difficulty in identifying patients and others who might be present or overhearing confidential conversations.¹²

The likely impact on health inequalities must also be considered given that 11 million people (20% of the UK population) lack basic digital skills.¹³ These patients are more likely to be less well educated, older, unemployed, in social housing, disabled, homeless, and those for whom English is not their first language.¹³ Some also argue that we must get the basics right first, such as computer log-ins and Wi-Fi before spending on complex technologies.¹⁴

If we do not train clinicians and patients on how best to use and integrate digital technology with standard medical care, we risk creating a parallel digital health system. Will patients use a symptom checker app or book a GP appointment?

The psychological burden of health data and impact on patient wellbeing must also be considered, for example, anxiety about REM sleep activity or low-risk gene profiles via private genetic screening tools.

Digital ethical issues need to be incorporated into safeguarding training, training on documentation, and storage of data and awareness of digital exclusion and equity.