Is the routine recording of primary care consultations possible … and desirable? Lessons for researchers from a consultation with multiple stakeholders

doi:10.1016/j.pec.2010.04.020

Patient Education and Counseling

Volume 82, Issue 2, February 2011, Pages 247-253

https://doi.org/10.1016/j.pec.2010.04.020 Get rights and content

Abstract

Objective

To explore stakeholders’ attitudes towards routine, longitudinal recording of primary care consultations for research purposes, and to identify legal, ethical, and practical barriers and facilitators.

Methods

183 stakeholders (including patients, researchers and practice staff) were identified using a purposeful sampling strategy. Stakeholders participated in focus groups and interviews. The data was analysed thematically in an iterative manner with themes and questions from earlier discussions being raised with later participants.

Results

Most participants supported the creation of a database and believed it would benefit patient care. They suggested it could be used to train doctors, aid understanding of conditions, and feed information back to practices to improve performance. However, enthusiasm was tempered by concerns about the ownership security and access of the data; quality and limitations of the dataset; impact on behaviour; and workload. Safeguards were suggested that protected vulnerable individuals, enabled participation, gave control to participants, and clarified data use.

Conclusion

The findings show that collecting such longitudinal data is possible, valuable and acceptable providing certain safeguards are in place.

Practice implications

Future studies employing routine recordings of consultations should:

•
Attend to confidentiality, access and governance of the archive.
•
Collect quality data, and store it securely.

Introduction

Around 250 million GP consultations take place in the UK every year [1]. They are arguably the most important in health care because they provide a gateway to further care and can affect long-term health outcomes [2], [3]. Interactions within the consultation may also influence patient behaviour including lifestyle change [4], adherence [5], re-attendance and dis/satisfaction [6].

However, problems with the consultation such as, variations in disease detection, diagnoses, prescribing and referral behaviour suggest that patient outcomes may vary considerably between GPs and practices [7], [8], [9]. The lack of longitudinal data to link single or sequential consultations with outcomes means that the scale of this problem is largely unknown. Therefore such consultations offer tremendous opportunities for longitudinal research [10]. Longitudinal research that follows patients over substantial periods of time may facilitate the use of new and robust research methods to examine the causes and consequences of doctor, patient and contextual factors on patient behaviour, experience and outcome.

The clinical consultation consists of four key components: doctor's behaviour; patient's behaviour, their combined interactions; and context (e.g. time, location, duration, doctor/patient characteristics). Longitudinal research can identify elements within these components to predict longer term health outcomes, for example, the impact of the doctor's behaviour on the patient's disclosure of symptoms, adherence and lifestyle change, uptake of services and clinical outcome. Similarly, the language patients use to describe symptoms may influence the doctor's diagnosis and disease detection. This information could be extremely useful in informing effective and acceptable primary care consultations [11], [12], [13], [14], [15], [16].

To date most research on consultations has been cross-sectional and rarely linked to longer term outcomes [15], [17]. Such cross-sectional studies do not have the capacity to identify predictors of subsequent patient or professional behaviours or to link consultation events to clinical outcomes. Neither do they enable a true reflection of the nature of GP care which extends beyond a single session. There is therefore a need to develop longitudinal resources to examine the patient journey over time (through repeated consultations) that can be linked to subsequent outcomes or behaviours.

Previously, technical, ethical and logistical problems had largely precluded large longitudinal studies following patients over time. The technology was often complex and unfamiliar to health professionals and patients, who may have viewed the ongoing audio-recording of consultations as onerous. Longitudinal studies that were conducted were limited, in either having been interventions to improve short-term outcomes or qualitative studies exploring patient and clinician perspectives post consultation [18]. Nevertheless, these did develop theory, and valid and reliable ways of coding consultations, such as, RIAS and Verona CODES systems.

Although specific longitudinal data could be collected for individual research projects there are some key advantages of ongoing routine recording. Firstly, collecting and handling large amounts of consultation data can be costly; consequently, there are economies of scale from creating a database that can be used for multiple projects. Secondly, the existence of the dataset will reduce the time required to conduct future studies as the data collection will already be complete. Thirdly, the pre-existence of the data may aid researchers in obtaining research funding as issues of research feasibility are reduced (i.e. the data and data quality are already known).

The Scottish Clinical Interactions Project (SCIP) was a one-year study funded by the Scottish Funding Council, to explore the practical and ethical issues involved in routinely audio-recording GP consultations. Recent research indicated that new recording technologies offered easy, low cost data collection, storage and analysis and that creating such a database was now technically possible [2], [3], [4]. Moreover, these technologies were less likely to be considered threatening as recording equipment was commonplace in most homes, routinely used in GP training [5], [6], [7], [8], [9], [10] and research [11].

Although now technologically possible, would ongoing routine recording of GP consultations be acceptable to those taking part? Patients and professionals experience of participation in cross-sectional research that records consultations is generally positive and recruitment rates high [15], [17]. But such participation is time limited and makes fewer demands on participants. Its one-off nature also means the data can be more easily anonymised. In a longitudinal cohort study, the need to continually link each patient's subsequent consultation to the dataset could undermine attempts to irreversibly anonymise the records. Consequently, the views of patients, health professionals and other relevant stakeholders are crucial to the success of such an undertaking. However, such views are largely unknown.

To explore stakeholders’ attitudes to routine, longitudinal recording of GP consultations for research purposes and identify practical and attitudinal barriers and facilitators.

Section snippets

Methods

An iterative qualitative approach was adopted to ensure that the consultation process was comprehensive. The majority of data collection employed a focus group approach. This was for three reasons. Firstly, group interaction may generate views that might not otherwise emerge; this was particularly important given that discussion about a possible future experience (being recorded) rather than past or current experience. Secondly, focus groups enabled us to consult with a wider range of

Results

All stakeholders supported creating such a dataset and believed it would benefit health care. Enthusiasm was tempered by concerns about the ownership and security of the data; quality of data; limitations of the dataset; impact on behaviour; and staff workload. Nevertheless, solutions were suggested to overcome these.

Discussion

The consultation process suggests that there was considerable support for recording consultations for research purposes provided safeguards are in place. These must attend to the governance of the data; protection of vulnerable users; minimising workload, and safeguarding identity.

All stakeholder groups wanted strong governance of the data with restricted access. Patients should not be able to “trawl” the data looking for medical errors to support litigation. Such concerns have been addressed

Disclosure

We can confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

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Provider PerspectivesIs the routine recording of primary care consultations possible … and desirable? Lessons for researchers from a consultation with multiple stakeholders

Abstract

Objective

Methods

Results

Conclusion

Practice implications

Introduction

Section snippets

Methods

Results

Discussion

Disclosure

Patient Educ Couns

Cancer

Ann Oncol

Patient Educ Couns

Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials

Ann Fam Med

Interventions for providers to promote a patient-centred approach in clinical consultations [Systematic Review] Communication skills training for health care professionals working with cancer patients, their families and/or carers [Systematic Review]

Cochrane Database Syst Rev

Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol)

BMC Health Serv Res

A pragmatic cluster randomised controlled trial to evaluate the safety, clinical effectiveness, cost effectiveness and satisfaction with point of care testing in a general practice setting—rationale, design and baseline characteristics

Trials

Screening and diagnosing depression in women visiting GPs’ drop in clinic in Primary Health Care

BMC Fam Pract

Continuing professional development: behind the headlines: sexual health implications for nursing ethics and practice

Prim Health Care

Teenage health and the practice nurse: choice and opportunity for both?

Brit J Gen Pract

Sexual health

Brit J Gen Pract

Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients

BMC Fam Pract

The desk-top computer as a magic box: patterns of behaviour connected with the desk-top computer; GPs’ and patients’ perceptions

Fam Pract

Communicating about medications during primary care outpatient visits: the role of electronic medical records

Inform Prim Care

What can doctors do to achieve a successful consultation? Videotaped interviews analysed by the ‘consultation map’ method

Fam Pract

Physician–patient communication in the primary care office: a systematic review

J Amer Board Fam Pract

Provider Perspectives
Is the routine recording of primary care consultations possible … and desirable? Lessons for researchers from a consultation with multiple stakeholders