Enabling mainstream video call access to existing health services (and why video conferencing can’t cut it)
Superficially, turtles and tortoises look similar but live in very different ecosystems.
Fundamental differences ensure each flourish in their own environment. Flippers versus feet, for example.
In the same way, video consulting and video conferencing seem similar, but each has very different design requirements.
Introduction
Distinguishing between the terms video conferencing and video consulting sounds pedantic, and would understandably be meaningless for most.
However, if you're a program manager tasked with enabling mainstream video call access for patients, it can make all the difference.
Conferencing workflows are built for business. They are outbound, provider-centric and simple. They are designed to navigate people to a virtual meeting room where the provider (or the convener of a meeting) is located. Security and privacy concerns are inherently challenging in a healthcare context.
Patient consulting workflows on the other hand are in-bound, patient-centric and often complex. Designs need to align with the way health care works, and how people approach a service, as opposed to a room. Security and privacy is paramount.
The trouble is people buy in to the vision of video consulting, then try and use video conferencing to achieve that vision.
This is not to say that video conferencing cannot work for health care delivery; it can. Any video technology works up to a point. This is especially while volumes are low, or there is funding to compensate for the extra work.
However. to quote Eric Schmidt former Executive Chairman of Alphabet,
“Scale changes the rules, scale changes everything”.
The scale here is not technical scale, that is a given. What we are talking about is organisational and systemic scale. The capability to offer video call access as a normal part of managing a clinic. To make travel optional for everyone.
Spoiler alert: This is not a video technology contest for the most part. Conferencing and consulting solutions often use the same video transmission technologies (WebRTC in many cases today).
This is a workflow, operational, and service delivery challenge, where privacy and security are fundamental to the design at all levels.
Having been at the vanguard of using video technology in health care for over 20 years (read An Accidental Career in Telehealth) I’d like to share a few lessons, both as a video consulting program manager and, more recently, working with and helping others towards a shared vision.
In doing so, I would like to acknowledge the many, many people that have been part of the journey and contributed to the knowledge herein.
Its time to expand our horizon
Every time people present their telehealth projects at conferences, they talk about how many kilometres have been saved (and how many times around the world that is), the hours of lost productivity recovered, the carbon not emitted etc.
This is all true, and remarkably easy to demonstrate even with small numbers of consultations. The real value, however, comes with all the knock-on benefits that occur at a human, clinical, economic, and system level.
Its not the same as being in the room, but as with a physical visit, a video call can establish a human connection, help with comprehension, environmental context, empathy, commitment, as well as the opportunity for visual examination. In a video call even silences have meaning.
Studies (such as this large one by the Centre for Health Services and Policy Research, UBC) have shown an overall reduction in health system use by patients who were able to consult with their own primary physician via video. A 91% patient satisfaction rating was also recorded which is fairly typical.
Even with large investments in technology and people, and relatively low numbers of consultations, the overall business case is compelling. Which is what video conferencing companies put in their marketing.
It doesn’t matter if you are offering ad hoc video access using FaceTime or WhatsApp, or taking a more systematic approach, using commercial conferencing solutions in hospitals — it all works to a degree.
This is a large part of the issue — we think we are doing okay.
However, we are no longer talking about the tactical use of video conferencing to address specific needs. The drivers, and the opportunities are far greater now.
This is not only about reducing geographic isolation, but any isolation (for example, physical, mental, or economic — all of which can occur just as easily in urban areas, as rural); it’s also about convenience.
People can stay at work, or care for their families: and are more likely to keep appointments.
One Inflammatory Bowel Disease Clinic (IDB) clinic in Scotland regularly has 70–80% of patients attending via video, mostly from home, with all the benefits of being in their own environment, not having had the stress of the journey.
In Australia there are around 28 million outpatient services a year that were not related to procedures or diagnostics. Some anecdotal estimates suggest an average of 30–35% of outpatients’ visits may be possible via video call. In NHS Highland the target is 20% by the middle of 2019.
And that’s just hospital-based services. It doesn't include the approximate 185 million general practice, specialist, allied health and community mental health occasions of service in Australia each year. Human services; disability services; the list goes on.
Think of the human value, and all the other benefits for society we can achieve if just 5–10% of consultations could be accessed via video.
To reach this goal, a large proportion of our health service providers need to be able to say, ‘Yes, you can attend via a video call’.
And therein lies the rub.
The telehealth conundrum
Anyone with a web browser can participate in a video call, we all want the benefits, and this is the aim of multiple government initiatives. It’s seems like a no-brainer.
But there is a catch.
The main benefits of video consulting go to patients, their families and employers, to the system & to society as opposed to the providers of the health services.
Yet willing and able health care providers are critical for success.
Making it easy for busy clinic teams to say ‘Yes, you can attend via a video call’ has been my focus for many years. This has been both working at the Alfred Hospital and Monash University in Melbourne, and now with a much broader community of program managers through our work with Healthdirect Australia and the NHS in the UK.
While many health care providers are based in regional areas, most are based in metropolitan ones. I know from experience that enabling video call access in a major tertiary facility is hard, and enablement models that work in regional areas often do not work in the cities.
Achieving business-as-usual video call attendance in a busy clinic — what we have learned so far.
After assessing 7286 virtual visit encounters in Canada, involving 5441 patients and 144 physicians Dr Kimberlyn McGrail PhD concluded:
Getting a busy, often understaffed, clinic to offer video call access is getting easier, but still has its challenges.
While there is often empathy at a human level, it doesn’t really matter to them if a patient has traveled half the day or come from around the corner; they all walk through the front door, and there is a long queue.
If you want even 5% of patients to attend via video, there can be no operational difference for service providers between a patient attending in person, or one attending via a video call. You can’t just bolt on a video solution. Deep technical integrations of video technology within clinic systems isn't the answer either.
Reimbursement is a key factor of course, people need to be paid.
In my experience however, even with reimbursement, patient video access is only sustainable when it is pain free for the health care providers involved.
Practical, operational lessons we have learned in this regard include:
1. Familiar processes and simplicity are key to adoption
Video call attendance must align with the way physical consultations are managed and attended in everyday clinical settings. There can be no gaps in the process.
A video call is an alternative way of the patient arriving for their consultation. Instead of the street address, patients are given the health providers web site address. Everything else should remain the same.
Patients should not require apps, or accounts, or appointment specific links, or to sign-in or download software.
Everything that is different creates friction and / or risk.
It must be completely intuitive for clinicians to consider, approve, organise, and attend video consultations, from wherever they happen to be and importantly, at the point that the option needs to be considered.
Video consulting solutions must fit the models of care, not the other way around.
In order to achieve the level of flexibility required, video call attendance must be a simple, lightweight extension of existing systems and flows.
2. There can be no extra work or disruption for clinic staff
Additional resources should not be required to manage video call access. No parallel processes or systems for video consultations, and no creating virtual meeting rooms and sending links for every consultation.
Appointments should be scheduled and managed in the same way as for physical consultations, using the same administrative and clinical applications, with no need for scheduling-related, or technical integrations between video and the clinic systems.
Patients should be able to autonomously check everything works beforehand and just ‘turn-up’ as they normally would, except via the service web site.
Solutions must compensate for any gaps in the process created by the fact the patient is not in the same room as the clinician.
From a technology standpoint, the benchmark for usability, cost, convenience, and access needs to be the telephone.
3. Design must be patient-centric from top to bottom
A patient-centric design approach makes integrating with the care process much easier, however complex it is.
Examples
- It doesn’t matter if clinics are running late
- Its easier to guarantee privacy, with no digital footprint
- Patients can be transferred from one service to any other, be it internal or external
- Patients can be seen by any authorised clinician
This is particularly key for Integrated Care initiatives, and the cross-sector exchange of services. (including between public and private)
4. A decentralised model is key to rapid adoption and innovation
It is important to empower service providers and individuals by giving them the information and tools they need, so they don’t have to rely on central services. This can be done without compromising on governance and reporting.
A decentralised design approach supports scale and innovation, without increasing central costs.
Examples
- A decentralised support model (and technology architecture) supports scale, without increasing central costs
- Empowering service providers to manage access and permissions
- Sharing resource and materials during the adoption phase, to shorten learning curves, maintain quality, and reduce duplication
- Using modern web browser-only solutions (that don’t require centralised video infrastructure) to allow new initiatives to be trialed with a very low cost of failure
5. Simple experience for patients
Patients should have all the answers to their questions available on line and sent with their confirmation.
Patients should not need to install special software or sign up for anything or require dedicated dial-in instructions to enable the video call. It must be a simple click on the health care providers web site, and it must work first time.
Anything more complicated than that and it won’t scale sustainably from an operational perspective.
6. High levels of end-to-end privacy, security and data protection is paramount
An end-to-end focus on this is key to reducing risk, and ensuring clinician and consumer confidence.
For example, peer-to-peer video technologies such as WebRTC, are easy to implement at one level. However, doing so in a way that meets health-grade standards and consumer expectations is a very different story.
As the volume of consultations increases, it’s only a matter of time before the spotlight falls on the inherent risks related to the use of social video chat or conferencing solutions (in particular to privacy) that have not been configured or used in the required fashion.
The issue isn’t about the integrity of the actual video transmission, it’s what happens before, during, and especially after, the consultation that raises the risk profile.
7. Clinical applications configuration and BAU technical support
From an IT perspective enabling video call access is as much about configuring the administration, patient flow, and clinical applications (to be able to accommodate attendance via video), than it is about deep technical integrations.
Examples
- Clinicians are reminded to consider video call attendance as an option
- Clinic staff can select video call attendance as an option in the patient administration system
- Appointment letters include the service’s web page address (instead of the street address) to attend the appointment
- Administration systems indicate when an upcoming appointment will be attended via a video call
- Clinic systems recognise when patients arrive via a video call
- The online waiting area can be accessed from commonly-used administration or clinical applications
- Activity reporting systems have been configured
Support for video consulting should be considered a business-as-usual (BAU) component of providing desktop and application support to staff.
8. Invest in achieving the overall outcomes
Investments in program management must be a clinically- and operationally-led with a focus all the involved clinical, operational, management and technology layers across the organisation. There must also be a high degree of collaboration and co-design with patients, staff and other stakeholders.
Areas to focus on include
- Governance and related policies
- Financial models
- Patient experience
- Workflow integration
- Compliance and risk management
- Communications planning
- Fit-for-purpose technical capability
Get in touch through Attend Anywhere if you would like a paper on the types of responsibilities related to video consulting within an organisation.
Much of the above is not feasible using meeting- or conference-based approaches.
So — turtle and tortoises — why can’t we use video collaboration systems for consulting?
Many of the health care organisations I meet have invested heavily in video conferencing or unified communications strategy for video collaboration, often with a mix of technologies.
These are designed for business, and work well for meetings, education and care delivery between hospitals (ED to ED for example). So, when the time comes to offer video call access to patients, folk understandably assume the same systems will do the job.
And they can up to a point.
It’s easy to show these working in pilot projects, plus ‘we already paid for it’ and ‘we don’t want to support another system’ - these are common and understandable refrains.
I empathise — hearts are generally in the right place, and it does appear possible from a technical perspective. This is especially where additional staff resources compensate for the barriers, or if people just don’t know any better.
In 2008, when the team and I started exploring direct-patient-access, we used video conferencing. We started by sending links to meeting rooms and then, as we got more sophisticated, links to appointment times.
We didn’t know it at the time (we thought we were going great guns!) but in hindsight, shoehorning conferencing workflows into clinical service delivery settings was hard — ‘square peg / round hole’ sort of hard.
It created extra work, process gaps, and other workflow limitations, as well as issues with sustainability, privacy, flexibility, reporting, and risk that needed to be endured, or worked around at some cost, and these increased with demand.
Conferencing and consulting flows are different: in many ways, opposite
Conferencing flows are built for business. They are outbound, provider-centric and simple.
Conferencing is designed to navigate patients to the Provider’s room (hence provider-centric.)
Because it is based on predefined ‘slots’, each slot needs to be created, and connection details sent to all parties. (hence flows are outbound and simple.)
Extra effort is required to prevent unauthorised people entering a slot at any stage before, during, or after the consultation.
There are also a range of other workflow and privacy issues that present barriers to scale and sustainability and add risk. These include, for example:
- The clinician is running late or is not available
- A patient needs to be transferred to another service, or back to the desk clerk
- The patient tries to use the same link later
Most importantly, conferencing workflows do not align with how attending a consultation works, or how people navigate throughout a service.
Patient consulting flows are inbound, patient-centric and often complex
People are all given the same, persistent street address for the service and arrive either at a scheduled time or on a drop-in basis, depending on the type of service. (Hence flows are in-bound — people just turn up)
From there they are guided to their destination using several possible mechanisms, such as signage, receptionists, and flow systems. (hence flows are patient-centric)
The room the doctor is going to use is not known a long time in advance, and in-fact the patient may be seen by any authorised person depending on the nature of the service. Patients may also need to be directed to multiple service providers during their visit and may be joined by ancillary providers such as interpreters. (hence flows can be complex)
“We can make it work” I hear the IT Department and the vendors advocates say, “There are APIs, and we are adding a waiting room function…”
Adding a waiting room or a virtual ‘lobby’ in-front of a created video room slot helps address some of the limitations. As does integrating the conferencing system with the patient scheduling systems, so that - for example - when an appointment is made it creates a virtual meeting room slot automatically.
However, this does not change the inherent limitations of provider-centric architectures, especially in a busy hospital setting.
Why video consulting systems should not interoperate with conferencing systems
It makes life harder, and it’s not necessary.
“What is this heresy!?” I hear from video conferencing veterans. Now you really have gone too far.
I get it.
I have worked on some large-scale and successful national video conferencing-based telehealth programs (some of which are entering their 17th year), where interoperability between systems has been critical.
Let me be very clear: I am not saying interoperability is not needed.
Video communication interoperability between browsers and web standards is essential. Patients using the Safari web browser need to be able to consult with doctors using Edge or Chrome.
Similarly, signalling and messaging interoperability is key to workflow integration. For example, automatically marking people as ‘arrived’ in patient flow or clinic administration systems. Or in a different scenario, a clinician using Microsoft Teams to be notified their patient has arrived and be presented with a link to join them.
In the context of incoming patient consultations however, interoperability with your conferencing systems makes things much harder.
There are a several reasons for this; here are three.
- Presenting a single, online address for all patients is fundamental to seamless process and systems integration. Requiring that the patient or clinician be given a dedicated link or number to dial not only breaks that principle, it introduces a whole range of other limitations, barriers and risks.
- There is no obvious need. All that is required is a web browser. Assertions from the architects and bastions of conferencing-based telehealth aside, I have not seen a forward-looking, mainstream example where a patient attending a video appointment needs to connect to a traditional video conferencing client. Yes, there are corner cases, but not many.
- Centralised video servers add latency, security issues, and cost, whereas a peer-to-peer (browser to browser) video technology like WebRTC offers no license fees, and no need to traverse through a central data centre.
It’s horses for courses; however if you merge systems designed for consulting, with those designed for conferencing, you’re liable to end up with a donkey.
The Scottish experience
The Scots have extensive Skype for Business and video conferencing networks.
These are fit-for-purpose; they have cameras, speakers, microphones, and screens that cater for large groups in meeting rooms. They offer browser-based video calling (WebRTC) so people can participate from wherever they are and, thanks to central servers, they can support large volumes of participants in education sessions or meetings.
At the same time video consulting is being adopted extensively across the nation through initiatives such as NHS Near Me and many others.
Both are supported nationally by the same VC Support team.
The point is both conferencing and consulting happily co-exist — which prompts the question:
Why is NHS Scotland able to differentiate so easily?
For one thing, their network of telehealth, TEC, and eHealth professionals (who implement all sorts of tech-enabled care) are clinically-led. These are people that actually work in the clinics, manage appointments and consult with patients.
I’ve found them to be open-minded and not overly protectionist of existing methods, and they were willing to benefit from the work of peers in Australia, who were even more at the vanguard of direct-to-patient telehealth at the time.
They recognised that the monolithic, centralised, one-size-fits-all structures that served them well for 15–20 years (and remain useful) are not conducive to rapid innovation or flexible enough to deliver what is needed. They also present barriers to adoption that are no longer necessary.
Fundamentally though they understood that, like Turtles in water and Tortoises on land, approaches to video conferencing, and those for enabling patient video call access within a busy clinic, each require different tool sets.
Further reading: An Accidental Career in Telehealth provides insight in to the experiences that brought about the decentralised, patient-centric framework we use and advocate for today.
