Lockdown in many countries has affected the way in which healthcare workers interact with their patients. In the UK, for example, a number of medical consultations have gone online, with doctors trying to deal with their patients over Zoom or Skype – and it has not been easy. Lucas Seuren has been working in Oxford in a team actively exploring the costs and benefits of online medical consultation, and I’m delighted that he has agreed to send in a report from the front line.

The outbreak of the COVID-19 pandemic has radically changed the organisation of healthcare services. Social distancing protocols mean that face-to-face contact between patients and health care professionals has to be limited as much as possible. Consultations are now mostly conducted by telephone or video. This provides a unique opportunity for EMCA research on healthcare interaction, but also a significant challenge. Little is still known about how communication works in these remote service models, and as experts on social interaction, we are in a prime position to develop evidence-based guidance. The problem is: how do we get data when we cannot go to places where the interaction take place?

Our research group in Oxford (Interdisciplinary Research in Health Sciences) has been studying video consultations for nearly a decade, and we recently secured funding from the UKRI to investigate the new Remote-by-Default service models in primary care. This project involves a small work package in which we will be investigating how health care professionals assess potential COVID-19 patients during video consultations, with a particular focus on how they assess breathlessness and fatigue. So how did we address the challenges involved in doing this research?

Protocol

The first challenge in studying video consultations is figuring out how to record the data. This used to be relatively straightforward in the pre-COVID era. In previous research projects, we set up multiple cameras, both in the clinic and the patient’s homes [1, 2]. These would capture the participants as well as their screen and audio feeds (see for example figure 1). In this way, we could get a decent picture of what each participant was doing as well as what they could see and hear of their co-participant. In practice it was not always feasible to get all cameras set up and record in both locations, but we coped.

Figure 1: Four angles during heart failure video consultation

For our new research project, we had to develop a protocol that would give us decent quality data that was also ethically sound. We essentially had to deal with two problems. First, we did not actually have access to the consultations, and second, since we are dealing with acute and potentially serious COVID-19 cases, we could not secure informed consent from patients before the consultation.

Compromise! 

To even get data, we had to compromise on the quality. Many videoconferencing solutions like Zoom have built-in recording options, which would mean clinicians could simply record the consultation with the push of a button. Health care providers, however, frequently use specialised video consultation software, such as Attend Anywhere, in which recording is not possible. For these cases, we decided to opt for commercial screen and audio capture programmes that do the same job. In cases where this option is not available, we decided to opt for commercial screen and audio capture programmes that do the same job.

While fairly straightforward, the downside is that you get a very limited picture of the interaction. You only record what the clinician sees and hears on their computer, which is hardly the complete participants’ perspective. It provides few insights into how participants use the technology, the environment in which the interaction takes place, how lag and other technological disruptions shape participant behaviour, or how they use their bodies off-screen. We settled for this limited view, because given our research goals and the practicalities around social distancing, we think we can develop an adequate analysis with one-sided recordings.

Ethics

The bigger problem was setting up a recording protocol that would meet ethical standards. Our first proposal was for the clinicians to initiate the recording at the start of the consultation, in order not to delay the clinical assessment, and to inform the patients and secure verbal consent at the end of the consultation.

Informed consent is, however, not taken lightly, and so we had to make some adjustments. While we can still get verbal consent after the consultation has taken place, clinicians have to ask patients at the start of the consultation if they can record it. They then have to store the recordings until the point we have been able to talk to the patient, explain the study, and record consent. After that, we use secure data transfer services to move the recordings from the clinician to the secure servers in Oxford. It’s a bit of a hassle, but workable enough.

Fortunately for us, because our research was urgent, both our local Research Governance department and the Research Ethics Committee prioritised the study. Normally this process would likely have taken many months, but in this case we actually had REC approval in the first week of the study! That means that in little over a month we went through the entire research ethics procedure. Well, almost the entire procedure, since we will still need to secure local approval from each clinical site. But clinicians have been very keen to work with us, and so moving forward has not been much of a problem.

Evidence-based Guidance

The goal of this project is of course not simply to investigate how clinicians assess breathlessness and other COVID symptoms by video. We aim to develop evidence-based guidance on how to do this effectively and efficiently. There are currently no established and empirically validated tools [3]. CA can make a vital contribution to addressing the pandemic, because we can show in details which practices clinicians use (not only which ones they report using), how these are understood or misunderstood by patients, and what that means the clinical assessment.

The only real issue now is that lockdown measures have largely been so effective, few patients still call their GP because they might have COVID. We are told a second wave is likely inevitable in the autumn when life moves back indoors. On the one hand, I’d be very happy if that turns out not to be the case. But looking at how the virus is re-emerging in parts of Australia, France, Germany, and with a growing infection rate in the UK, it seems likely that the peak of our work is still to come.

References:

1. Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, et al. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. Health Services and Delivery Research. 2018;6(21):1-136. doi: 10.3310/hsdr06210.
2. Shaw SE, Seuren LM, Wherton J, Cameron D, A’Court C, Vijayaraghavan S, et al. Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: A Linguistic Ethnographic Study of Video-Mediated Interaction. J Med Internet Res. 2020;22(5):e18378. doi: 10.2196/18378.
3. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. Bmj. 2020. doi: 10.1136/bmj.m1182.