Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice

Background Increasingly, the NHS is embracing the use of digital communication technology for communication between clinicians and patients. Policymakers deem digital clinical communication as presenting a solution to the capacity issues currently faced by general practice. There is some concern that these technologies may exacerbate existing inequalities in accessing health care. It is not known what impact they may have on groups who are already marginalised in their ability to access general practice. Aim To assess the potential impact of the availability of digital clinician–patient communication on marginalised groups’ access to general practice in the UK. Design and setting Realist review in general practice. Method A four-step realist review process was used: to define the scope of the review; to search for and scrutinise evidence; to extract and synthesise evidence; and to develop a narrative, including hypotheses. Results Digital communication has the potential to overcome the following barriers for marginalised groups: practical access issues, previous negative experiences with healthcare service/staff, and stigmatising reactions from staff and other patients. It may reduce patientrelated barriers by offering anonymity and offers advantages to patients who require an interpreter. It does not impact on inability to communicate with healthcare professionals or on a lack of candidacy. It is likely to work best in the context of a pre-existing clinician–patient relationship. Conclusion Digital communication technology offers increased opportunities for marginalised groups to access health care. However, it cannot remove all barriers to care for these groups. It is likely that they will remain disadvantaged relative to other population groups after their introduction.

assess the potential impact of the availability of digital clinician-patient communication on marginalised groups' access to general practice in the UK.

METHOD
A realist review was conducted using a fourstep process: 24 • define the scope of the review; • search for and scrutinise evidence; • extract and synthesise evidence; and • develop a narrative, including hypotheses. This review method was selected because it allows investigation of what works, for whom, in what circumstances, in what respect, and why; it draws on material from across disciplines and is not restricted by literature type. The review sought to understand how the intervention (digital clinical communication) works in specific contexts (groups marginalised from general practice access) with what outcome (access to clinical care in general practice).

Define the scope of the review
In order to define the scope of the review the literature was searched for opinion pieces and empirical evidence of health professionals' views on the benefits of digital communication. 11,[25][26][27] The authors consulted with 32 GPs and 20 physiotherapists via brief surveys and discussions at professional development events. Over 200 primary care patients of all ages were consulted on their views using the following methods: electronic surveys to GP patient panels, discussions at patient consultation meetings, and surveys undertaken by school-aged children among their peers. Consultations continued until no new opinions were found.
Drawbacks and benefits were identified relating to access, particularly for marginalised groups who find access difficult. It was decided to focus the review on access and the following research questions: • What are the barriers to accessing general practice for marginalised groups?
• What impact would the use of digital communication between clinician and patient have on the ability of marginalised groups to access general practice?
The following technologies were included: video technology, e-mail and internet forums, and short text media (SMS). The following marginalised groups were investigated: people with mental illness, refugees, asylum seekers, homeless people, Travellers, and carers.
Search for and scrutinise evidence Review 1. What are the barriers to accessing general practice for marginalised groups? A systematic search was conducted for relevant literature (Box 1). Included were English-language papers of empirical research or systematic review conducted in any country. Titles and abstracts were screened initially, and reference lists were screened to identify any further relevant papers. The quality of included studies was assessed to aid in contextualising the findings of the review, rather than to exclude poor-quality studies. Critical Appraisal Skills Programme (CASP) qualitative, cohort, and review appraisal tools were used, 28 scoring 1 (for 'yes'), 0.5 (for 'unclear'), or 0 (for 'no') for each item on the checklist. Review 2: What impact would the use of digital communication between clinician and patient have on the ability of marginalised groups to access general practice? Two complementary approaches to finding relevant evidence and theory were used. First, a systematic search for relevant literature was conducted (Box 1), looking for studies set in either primary or secondary care. Titles and abstracts were screened to identify empirical studies specific to the access issues identified in Review 1.
The second approach involved an iterative process of discussion, literature search and review, further discussion, and further literature search and review. Each access barrier for each marginalised group was discussed (from Review 1) and how digital communication could operate to improve access or not was identified. Multiple disciplines were purposively searched (using multidisciplinary search engines, such as Web of Knowledge and Google Scholar) for relevant empirical and review papers, and for well-established theory. These provided evidence to support or refute the authors' ideas as to whether or not digital communication would improve access, and for alternative mechanisms of action of digital communication for each marginalised group. Search, review, and discussion continued until no new information was found.

Extract and synthesise evidence
From relevant papers found through both searches, the evidence and theory relating to each access barrier faced by a marginalised group was summarised. Then the impact that digital communication between clinician and patient would be likely to have (improved access to clinical care in general practice or not) was identified. Relevant research results were extracted and thematically coded.

Develop a narrative including hypotheses
The barriers to access and the groups known to experience each barrier along with the evidence for the barriers were described. Evidence was then juxtaposed for the impact of digital clinical communication on the barrier. From this, hypotheses were developed of the impact of digital clinical communication on the barrier in question.

RESULTS
During Review 1, 43 relevant studies were identified ( Figure 1) and, during Review 2, 17 relevant studies were identified. An additional 10 studies were identified during the purposive search element of the review (additional details are available from the authors on request). Papers for Review 1 were predominantly qualitative and crosssectional studies, many with methodological weaknesses. Review 2 included theory, experimental and qualitative research, and systematic reviews. Evidence for both reviews was from high-income countries.

Synthesis of findings
Six barriers to access and evidence for how digital communication may impact on these barriers were identified: practical access issues; lack of candidacy; lack of ability to communicate with healthcare professionals; patient-related barriers; negative experiences with healthcare service and staff; and stigmatising and negative reactions to patients.
Practical access issues. These were experienced by carers and people with mental health problems. The barriers identified were lack of respite care for care recipients, 29 inflexible appointments, 30 unknown waiting times, 30 service availability, 1 transport difficulties, [31][32][33] difficulties negotiating appointments and receptionists, 34 and the stress and discomfort of waiting in the waiting room. 34 Digital clinical communication improved access to general practice as practical barriers were overcome. E-mail offered efficiency, speed, and flexibility, for example, patients and carers could use e-mail to communicate with their clinician while at work. 13  Search terms (all terms were MeSH terms, except for those marked † ) Review 1. What are the barriers to accessing general practice for marginalised groups?
Medline, CINAHL, EMBASE, PsycInfo, ASSIA, and Web of Knowledge "General practice" and "access" † were combined with the following within each database: "mental health" or "mental illness", or "carer"*, or "refugee"* or "asylum seeker" † or "homeless" † or "gypsy" † or "traveller" † Review 2. What impact would the use of digital communication between clinician and patient have on the ability of marginalised groups to access general practice? a Medline, CINAHL, EMBASE, PsycInfo, ASSIA, and Web of Knowledge "email" or "electronic mail" or "text messaging" or "SMS" † or "voice over internet protocol" † or "skype" † and "primary healthcare" or "primary care" and "access to healthcare" † or "health services accessibility" a The iterative searches for Review 2 are not included here. can be used to communicate whenever is convenient for the patient or carer, reducing the need to negotiate receptionists or appointment systems, travel to the surgery, and use waiting rooms. [35][36][37][38] Lack of candidacy. This was experienced by carers. The barrier identified was that health professionals focus on the needs of the care recipient, with the needs of the carer considered only in terms of what is needed to provide care. 30,[39][40][41][42] Increasing the range of channels through which carers can access general practice will not impact on perceived candidacy because identifying oneself as a candidate for health care is necessary before starting the help-seeking process. 43 Lack of ability to communicate with healthcare professionals. This was experienced by refugees and asylum seekers, and people with mental health problems. The barriers identified were language barriers affecting the appointment booking and consultation, [44][45][46][47][48][49][50][51][52][53][54][55][56] problematic access to professional interpreters, 44,48-50,52,57-59 confidentiality fears with both professional and informal interpreters, 44,49,58 and lack of discourse to describe mental health concerns. 60,61 Digital clinical communication will not change the ability of these disadvantaged groups in communicating with health professionals, with the exception being language translation. There is an increased feeling of privacy when an interpreter is not physically present, which increases willingness to discuss sensitive issues. 62 However, people whose first language is not English are not heavy users of digital communication in English-speaking countries, 16,63 so this advantage may not be realised.
Patient-related barriers. These were experienced by refugees and asylum seekers, homeless people, and Gypsies and Travellers. The barriers identified were mobility of populations and lack of continuity, 51,58,64 unwillingness to divulge address (for personal safety, such as women living in domestic violence shelters, or fear of legal repercussions, such as failed asylum seekers), 65 and patients' lack of knowledge about health service structure and how to access services. 47,50 Digital clinical communication improves continuity of care for mobile populations and those unwilling to divulge their address, 13,66,67 and the relative anonymity provided could encourage populations who wish to remain hidden to seek help. 66,68 However, this type of communication alone will not improve knowledge about health service structure and how to access services. The authors were unable to find any evidence on these factors.
Negative experiences with healthcare service and staff. This was experienced by people with mental health problems, refugees and asylum seekers, homeless people, and Gypsies and Travellers. The barriers identified were staff not being seen as sensitive, 44 60 and service-wide lack of awareness of patients' rights and acceptance of official documentation. 52,58 Digital clinical communication will improve continuity of care from a trusted clinician, but where there is no existing patient-clinician relationship it will reduce the quality of communication between patient and clinician. Social presence theory 76 states that interpersonal processes are negatively affected by interaction that takes place via media that reduces the feeling of 'being there' with each other. In order to build the therapeutic relationship, clinicians and patients need to have face-to-face contact for the richness of stimuli available, including auditory, visual, tactile, and olfactory. 37 Patients try to see trusted GPs for mental health issues rather than the most available GP, 77,78 prioritising relationship continuity over convenience. Text-based communication in well-established relationships is likely to be more successful than that between strangers because of the room for misinterpretation. 37,79 Additionally, digital clinical communication would reduce the need for patients to engage with receptionists and other health centre staff, [35][36][37] ameliorating apprehension about negative experiences with these staff.
No evidence was found that digital communication will in itself improve patients' trust in general practice clinicians, or increase health services' awareness of patients' rights.
Stigmatising and negative reactions to patients. This was experienced by people with mental health problems, refugees and asylum seekers, homeless people, and Gypsies and Travellers. The Digital clinical communication may reduce patients' inhibition and sense of intimidation, and promote patient disclosure and asking of questions. Patients consulting for physical problems feel less intimidated via video link and able to ask more questions. 90 Kang and colleagues 91 found that teenage girls willingly emailed a health professional in a magazine column to discuss problems/ queries that they would not necessarily talk about face to face. Online disinhibition theory 92 suggests that people express themselves more openly, disclose more, and say things in cyberspace that they would not face to face. The removal of the patient 'being seen' seeking help potentially removes the embarrassment, social disapproval, and stigma that some patients may experience at healthcare centres. 68,93 Although one review suggested that faceto-face consultations were essential for communication about emotional states, 87 other evidence suggests that patients do communicate their emotional states with GPs via e-mail, 88 and are able to discuss embarrassing or sensitive questions. 89 Table 1 summarises the barriers to general practice access, groups known to experience each barrier, evidence for the impact of digital clinical communication on each barrier, and emerging hypotheses of the impact of digital clinical communication on the barrier in question.

DISCUSSION Summary
This study assessed the potential impact of the availability of digital clinician-patient communication on marginalised groups' access to general practice in the UK. It has demonstrated that digital communication between clinician and patient has the potential to overcome the following barriers for these groups: practical access issues, negative experiences with healthcare service and staff, and stigmatising and negative reactions from staff and other patients. It may reduce patient-related barriers by providing a level of anonymity and offers advantages to patients who require an interpreter to consult. It otherwise does not impact on a lack of ability to communicate with healthcare professionals, nor on a lack of candidacy and knowledge about health services. It is likely to work best in the context of a preexisting clinician-patient relationship.

Strengths and limitations
By using a realist approach for the evidence British Journal of General Practice, December 2015 e818 • Social (dis)approval 31,73 • Perceived discrimination 32,73,86 One review suggested that face-to-face consultations were essential for communication about emotional states. 87 Other evidence suggests that patients do communicate their emotional states with GPs via email, 88 and are able to discuss embarrassing or sensitive questions 89 Patients consulting for physical problems can feel less intimidated via video link and able to ask more questions 90 One review found that teenage girls willingly emailed a health professional in a magazine column to discuss problems/queries that they would not necessarily talk about face to face 91 Online disinhibition theory suggests people express themselves more openly, disclose more, and say things in cyberspace that they would not face to face 88 The removal of the patient 'being seen' seeking help potentially removes the embarrassment, social disapproval, and stigma that some patients may experience at healthcare centres 68,93 Digital clinical communication will reduce patients' inhibition and sense of intimidation and promote patient disclosure and asking of questions review, evidence was drawn from many disciplines to answer a research question for general practice, at a time when little good-quality evidence exists, and before the UK NHS has systems in place to support digital communication between clinician and patient. This is important for establishing realistic expectations of the benefit of digital communication between clinician and patient. The review drew on evidence from multiple disciplines and types of healthcare provision. So, although focused on general practice, the review results are likely to be relevant for other healthcare settings where the clinician-patient consultation is a key element.
The review does not include all marginalised groups. It did not include people with physical disabilities because the benefits of not needing to physically access a building are apparent. It did not include people for whom the use of digital communication is dependent on adaptation of the user interface, such as those with a sensory or learning disability. The marginalised groups included are likely to share characteristics with marginalised groups that were not included, such as sex workers. 94 However, it was not possible to identify research evidence on the relative advantages and disadvantages of digital communication with visual cues such as videoconference, compared with textbased cues such as e-mail. As the review considered UK general practice, where health care is free at the point of access, it did not consider whether the use of clinician-patient digital communication would improve access through reducing the cost for the patient.

Comparison with existing literature
Clinician-patient interactions are changing, becoming more patient centred, 95,96 and increasingly health professionals are promoting flexible approaches to consultations. 97 The review concurs with previous research findings that digital communication between clinician and patient increases patient flexibility, choice, and convenience. 37,98 However, use of the technology could create access problems if availability of traditional consultations were considerably reduced because the quality of the consultation is better if there is a pre-existing clinician-patient relationship.
It seems that provision of digital clinician-patient communication could improve access for some marginalised groups. However, such provision will be inconsequential for many people unless widespread access to the internet improves, websites and text-based communication conform to accessibility and plain-English standards, and assistive technologies are used. 15 Although this review suggests that the use of communication technology could improve access for homeless people, these people are often physically excluded from public internet access points. 99 Furthermore, people with more chaotic lives use such technology sporadically and not dependably. 99

Implications for research and practice
The World Health Organization has established the goal for all people to have access to timely, acceptable, and affordable health care of appropriate quality. 100 There is widespread expectation that the use of digital communication between clinician and patient will improve access to health care for marginalised groups. This review suggests there are likely to be some benefits. However, many barriers will remain and not all marginalised groups will be able to gain benefit due to their limited access to digital communication technology. As the benefits of increased access for marginalised groups also apply to non-marginalised groups, the provision of digital clinician-patient communication could potentially be monopolised by those who are already well able to access services and have good access to digital technology. This is something that is yet to be investigated. The cost to both health service providers and patients will also have implications for patterns of access. There is therefore a need to evaluate the impact of the introduction of digital clinician-patient communication on population patterns of access to health care. Further research is needed to understand how digital communication impacts on the acceptability and quality of health care. This includes the impact on clinician-patient communication and the relative advantages and disadvantages of communication with and without visual cues.
In conclusion, digital communication technology offers increased opportunities for marginalised groups to access health care, and general practice can make the most of these. These technologies cannot, however, remove all barriers to care for marginalised groups and it is likely that these groups will remain disadvantaged relative to other population groups, even after their introduction. Ethical approval Not applicable.

Provenance
Freely submitted; externally peer reviewed.

Competing interests
The authors have declared no competing interests.

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