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Practice Practice Pointer

How to conduct written online consultations with patients in primary care

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n264 (Published 24 February 2021) Cite this as: BMJ 2021;372:n264
  1. Minal Bakhai, clinical director for Digital First Primary Care, general practitioner for NHS Brent CCG1,
  2. Helen Atherton, associate professor2
  1. 1NHS England and NHS Improvement London, Skipton House, London SE1 6LH, UK
  2. 2Warwick Medical School, UK
  1. Correspondence to: M Bakhai minal.bakhai1{at}nhs.net

What you need to know

  • Have a blended approach to communication (using text, online message, phone, video, and face-to-face consultations) focused on patient need

  • Written online consultations work best in the context of an existing healthcare professional-patient relationship

  • Draw on your current skills and clinical acumen in conducting consultations and apply these when consulting online

  • The experience of the personal communication matters more to patients than the consultation modality

A written online consultation is a two-way written exchange between a healthcare professional and a patient using an online medium (such as an online web platform or email portal). Such exchanges offer an alternative route of access for patients alongside telephone and face-to-face consultations. This article offers a guide to help clinicians, particularly those working in primary care, use written online consultations effectively with their patients.

Where are written online consultations used in primary care?

Use of written online consultations has increased over the past decade, with many health systems adopting them as a way for primary care staff to interact with patients.1234 Arrangements for written online consultation vary between different countries and healthcare providers. In Denmark, offering patients email consultation has been mandatory in general practice since 2007, and 21% of all consultations were conducted this way in 2019.5 In England, general practices have been encouraged by NHS England and NHS Improvement to adopt online triage platforms. These offer patients a secure way to send a request or message to their practice via a structured online form.67 US health maintenance organisations have for many years used patient portals to facilitate this type of communication.89 The covid-19 pandemic has accelerated adoption of written online consultation because it offers communication without proximity.1011 Many primary care health professionals will now be encountering this form of consultation with patients for the first time.

What is the evidence base?

Evaluating online written consultations has to date been challenging because of differences in the way different approaches are implemented and delivered, the complexity of factors that influence change, low uptake by patients, and, for quantitative studies, a lack of standardised approaches to recording consultation type use in practice.12 To date, evaluations have mostly been small scale and short term or have been exploratory in nature.

A 2012 Cochrane systematic review of email consultations found the evidence to be equivocal in relation to impact on workload and clinical outcomes in primary care settings.13 A 2019 systematic review of e-consulting (including written online consultation) examined 57 studies, many of which were small studies.14 It reported that uptake and utilisation of e-consulting tended towards younger and employed adults, with acceptability and ease of use strongest in those with long term conditions and living in remote areas. Patients reported improved communication and increased engagement. Primary care professionals expressed fears about potential impact on workload, expectations of a quick response time, and the need for guidelines on the rules of engagement and communication strategies. A 2019 rapid review focused on “digital first primary care”15 found a lack of quantitative empirical data. It reported concerns from healthcare professionals about implementation and the potential for inequitable access to services for patients. Possible benefits included the ability to maintain continuity of care with a specific clinician. Included studies reported that written online consultations were popular among some older patients, patients who find face-to-face consultations difficult, those with hearing, mobility, or anxiety issues.15

A 2015 realist review examining use of digital communication with marginalised groups found online written consultations offered advantages—including for patients who required an interpreter, who had practical access issues, who had had a previous negative experience or stigmatising reaction, and who felt uncomfortable raising the concern face to face (such as a sexual health problem)—and that they worked best in the context of an ongoing doctor-patient relationship.16 The reviews that examined safety issues did not identify problems.131415 At present there is a lack of definitive data on whether workload changes when introducing and using written online consultation. Multiple factors affect the workload in using written online consultation, including the implementation strategy, messaging functionality within individual systems, and patients’ threshold for requesting a consultation.1317 More evidence is emerging, including from a recent analysis of routinely collected data from UK general practices using one online triage platform. It found a relative reduction of 3.4% in emergency department attendances in 2019 in practices that had adopted the online triage platform before mid-2019 compared with those that introduced it during the pandemic.11

How to conduct a written online consultation

Key steps to consider when approaching a written online consultation are summarised in the infographic. Written online consultation should be considered part of a dynamic primary healthcare model and not a stand-alone service. This is not a bolt-on service but a change to practice systems and workflow and requires the involvement of the whole team and patients.6 Box 1 offers our suggestions for how to incorporate this mode of consultation into a general practice service.

Box 1

Integrating online written consultations in general practice

Providing an inclusive and equitable service

  • Maintain a multi-modal service

  • Written online consultations represent a big change in how patients engage with their healthcare professional. Some patients may need training and guidance to support them. Human support is particularly important when patients have low levels of health literacy18

  • To improve inclusion, consider:

    • Free internet access at strategic sites

    • Improved readability and cultural acceptability of online health information and communication

    • Skill development for online access or additional support from a care facilitator1920

  • Annotate records for those who may find it challenging to use online consultation tools (such as those with learning difficulties, visual impairment, or poor access to devices and data)

Encouraging patients

  • Ask patients about their communication preferences and needs. Avoid making assumptions about who is able or wants to use digital channels

  • Ask all practice staff to promote written online consultation at each interaction with patients or as part of a follow-up message

  • Consider using an agreed script to help staff explain to patients how they can access services, what to expect, and how the service is working to keep patients (and others) safe in the context of covid-19

  • Co-produce communications and proactively raise awareness with local diverse and inclusive patient communities

  • Use practice, patient, and community champions as trusted digital facilitators

  • Proactively seek patient feedback on what would make them more or less likely to use online consultation tools

Involving practice staff

  • Ensure that the reception team are well informed about what written online consultation tool is available and what benefits the tool can offer

  • Ensure the reception team feel confident in explaining that the patients will receive care when they need it, from the right clinician. This may include reassurance that face-to-face care always remains available when clinically appropriate

  • Maintain an up to date and accessible practice website that works across multiple devices to maximise reach. You can use website analytics to prioritise how services and information are displayed on your home page so it is clear, easy to navigate, and structured around user needs

  • Be aware that members of the practice team will adapt to new systems at varying rates, with some requiring longer periods of support to adjust

  • Ensure patients are made aware of this option using as many routes as possible, such as social media, SMS, practice newsletter, information at registration

Communications with patients

  • Ensure that the primary care practice website or web platform in use provides clear information about the rules of engagement and what goes on “behind the scenes”—for example, who will see the written online consultation, how a problem will be dealt with, how information will be kept afterwards, and the code of conduct. Include:

    • Service hours and response times (in-hours and out-of-hours and for clinical and administrative queries)

    • How to use it and what to do if they have a medical emergency

    • How a response will be received and what to do if it is not or symptoms worsen

    • How a patient can get help for an urgent clinical query, particularly out-of-hours

    • What happens to photos, if and where they will be stored21

    • Advice for safe and proportionate image sharing21

    • How to navigate to information on self care and local self referral services

  • Patients may be worried that something written is not as confidential as something said face-to-face. Reassure patients that this consultation type is secure and that the information sent is saved confidentially in their medical record. Many systems allow patients to receive a copy of their written online consultation

  • Reassure patients that an online written consultation is not a “lesser” form of a consultation, but it is different. It is convenient for many patients, and the written medium means they can take time to consider their message and to read information2223

RETURN TO TEXT
Figure1

When choosing and setting up an online consultation platform,724 important considerations include25:

  • The use of questionnaires that are structured, use plain language, and offer a flexible approach can help patients to clearly detail their problem(s) and needs. Consider factors that may affect usability such as the length of time taken to set up and complete a consultation and the number of pop-ups patients will have to navigate (versus their intended benefit in providing safeguards for clinician and patient safety), tailoring these to local patient need and practice workflow processes.

  • The availability of functionality offered by the online system to assist with verifying patient identity.

  • Patients appreciate a consultation that feels personal and allows them to get a prompt response, even if this is simply letting them know that their query is being reviewed.

  • To enable continuity of care, patients should be able to address the written online consultation to a specific clinician or the system should display a rota of who is available.

The patient completes a written online consultation

Written online consultations are commonly used for clinical administrative requests, medication queries, simple clinical queries, follow-ups, long term condition surveillance, risk factor monitoring, and providing advice and information.262728 The clinical topics addressed tend to closely mirror those seen in a face-to-face consultation.293031 The consultations can also be used to keep patient contact details up to date.

Online consultation systems can also be used to gather more detailed information to support decision making—patients can send photos, audio or video files, remote observations, and attachments—and to follow up or monitor patients more easily. Consider if it is practical for the patient to take a photograph (such as, of certain areas of the body) if they have restricted dexterity or require a carer to help (and whether they would feel comfortable with this).

The primary care practice screens the patient’s message

When the practice receives a request from a patient via the online consultation platform, this should be screened and directed to the most appropriate member of staff. This allows for administrative tasks to bypass a clinician and for effective use of the primary care clinical team (pharmacist, care coordinator, nurse, etc). This can be done by an appropriately trained member of the administrative team2232:

  • The staff member screening requests can direct any obvious “red flags” to a clinician in the same way they would do with a telephone contact.

  • Where possible, try to ensure continuity of care and pass the consultation to a clinician already known to the patient, particularly if the request is about an ongoing or non-urgent problem, when this is not possible, maintain effective communication between professionals.2233

  • It’s a continuous learning curve. Seek feedback from patients and staff to keep improving your processes. Use patient feedback questionnaires and routine reports to understand demand patterns, assess outcomes, and improve the service.

Responding to a written online consultation

Review and prioritise the patient's request based on the need and consider the most appropriate method of response: this might be a written reply, a telephone call, a video call, or a face-to-face appointment. Take a risk stratification approach, considering the clinical, technical, and socio-cultural context. Consider the person’s preferences and accessibility of the format; the complexity, acuity, and urgency of the health need; your familiarity with the patient, their history and the psychosocial context to judge their current state of health; the potential risk of harm from the intervention; patient experiences that may make it more difficult to develop trust such as trauma, stigmatisation, or discrimination; the patient’s ability to have their voice heard and maintain autonomy in managing their healthcare; the need for a physical or visual assessment of the patient; and the ability to establish a two-way dialogue and share information in the way the patient understands or needs. Review and act on information presented in line with your clinical judgment as you would with any other consultation type. Be flexible and change the consultation method as needed.

There are many similarities with other forms of communication. For instance, we suggest writing in the tone that you would normally use with the patient.526

  • Write in a structured way, keeping sentences short.

  • Introduce yourself, your role, consider stating your gender (such as “I’m Dr X, one of the female GPs at the practice”; as it may not be obvious from an unfamiliar name.

  • Briefly summarise what the patient has written to confirm you have understood their point and the patient’s expectations. However, don’t be tempted to repeat taking the whole history. Clarify specifics or check if anything has changed if needed. This also reassures patients that you have read what they have written.

  • Offer to explain anything again and ask the patient if they have any questions.

  • Be specific about what will happen next.

  • Share an agreed summary or management plan electronically and consider enabling full record access so patients can refer back to the consultation.

  • Have a threshold at which you revert to telephone, video, or face-to-face consultation if the conversation is lengthy, not going well, or a deeper discussion is required.

Managing risk

It can be difficult to identify cues and clues when consulting online. Be aware of the challenge of not missing these, and be prepared to switch consultation method when needed. There is little research to indicate whether misunderstandings are increased or reduced with written online consultation34:

  • An established patient-clinician relationship makes a written online consultation easier,35 reduces the potential for miscommunication, and provides a better understanding of what “normal” is for the patient.

  • You may need to follow up with a telephone or face to face consultation in cases where a detailed history or discussion is needed. Non-verbal cues may be more important with some patients, such as those with learning difficulties or language barriers, where history taking may be more challenging.

  • Remain professionally curious and be vigilant to safeguarding, capacity, and privacy issues. If you have concerns arrange a face-to-face assessment.

  • Be alert to written cues and clues—for example, through the language used, literacy and language skills and consistency of responses; disproportionate or unsolicited intimate image sharing21 and alerts in the patient’s clinical record. If an online request has been submitted by a proxy, check their relationship with the patient and that consent has been given by the patient where appropriate.

  • Follow up online requests from young people under 16 years old with a face to face assessment to determine whether the patient is capable of giving informed consent to medical treatment without the knowledge or permission of their parents (or legal guardian) and whether this is in their best interests, following the principles of Gillick Competence.21

  • Ensure clinical safety risk management processes have been applied to your implementation strategy for online consultation systems.3637 Have a robust policy for clinically triaging incoming online consultation requests to avoid missing urgent issues and flagging requests from patients known to be vulnerable, children, and young people—with a low threshold for seeing them. Take into consideration who initiated the consultation, the patient’s engagement with health and care services and choosing a consultation method that enables the person to talk about private concerns confidentially.

  • Discuss cases with colleagues or take peer reviewed decisions.

  • If a patient has repeatedly consulted about the same problem online or has multiple failed encounters, offer them a face to face or telephone appointment.

  • To support the patient’s understanding of the consultation, it can be helpful to summarise key points and ask, for example, “Are you in agreement? Is there anything important I’ve missed?” and attach a link or digital leaflet to information, to consolidate your mutually agreed plan. Safety-net, explicitly highlighting red flags, particularly as you have not been able to see or speak to the patient.

  • Fears that healthcare professionals will be overwhelmed with lengthy exchanges that take up time by using written online consultation have not been realised. A UK based analysis of email consultations found that the median number of emails in a consultation was two and the median number of days from the first to last email was three.3839

Adapting to written online consultations

Written online consulting is a new skill, and adapting to it can be cognitively demanding. Healthcare professionals facing the greatest transition and adaptation often require enhanced training and longer periods of support.40 There is no “one size fits all” approach for training.

  • Provide space for peer review, debriefs, and discussions.

  • Create routine with regular “huddles” and check-ins for the whole team to share learning and feedback. Consider a shared working space (while adhering to any social distancing rules for the workplace). Teams with a strong foundation have found remote working easier and are better able to realise the benefits.41

  • Join existing communities of practice for generating collective learning and clinician crowd-sourced advice.

  • Ensure all staff receive training in using the systems and test the pathway to see how it works from the patient perspective.

Additional educational resources

Resources for clinicians

Resources for patients

Education into practice

  • Peer review written online consultations as part of ongoing team training to improve quality and appropriateness

  • Design a crib sheet with your team with key messages and frequently asked questions to ensure patients get a consistent message and to help staff answer queries more easily

How this article was made

This work draws on an evidence based toolkit devised by NHS England24 and on an evidence based toolkit32 devised by researchers in how to use alternatives to face-to-face consultations. The advice presented here is additionally informed by research conducted by author HA, including a published review42 and published research in this field, including the most recent evidence synthesis conducted.1415344344

How patients were involved in the creation of this article

A draft of this article was shared with the Patient Public involvement reference group linked to the Unit of Academic Primary Care, Warwick Medical School, via Helen Atherton and the Community Barnet Primary Care Group, via Minal Bakhai. Recommendations were made on all parts of the draft by participants. Of particular note detailed suggestions were made to sections on accessibility, privacy and security.

Footnotes

  • Contributors: MB and HA conceived the article and are guarantors. Both authors wrote and reviewed the article, created the boxes, and helped with the infographic

  • Competing interests: We have read and understood the BMJ policy on declarations of interests and declare the following interests: HA receives research funding from NIHR as chief investigator and co-investigator on projects relating to the critical evaluation of digital applications in primary care. She is lead supervisor for a collaborative PhD studentship partly funded by Advanced and partly funded by University of Warwick. In 2017 she received data at no cost from askmyGP to conduct independent analysis, this work was conducted by a medical student as part of a funded placement and published in the British Journal of General Practice. She is a member of the Primary Care Digital Transformation Board at NHS England, and the Scientific Foundation Board at the Royal College of General Practitioners.

  • Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

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