The conventional system of general practitioner (GP) referral of patients to hospital specialists in the UK is often associated with unnecessary duplication of investigations and treatments. Outreach clinics, in which hospital-based specialists provide outpatient services in primary care, have been established to alleviate this problem, but lack of involvement of GPs is thought to have limited their success. Researchers in the UK have now established "virtual" outreach programmes in which both the patient and GP attend a virtual consultation with a specialist via video conferencing. In the largest ever randomised trial of telemedicine, the Virtual Outreach Project Group, led by Paul Wallace from the Royal Free and University College Medical School, London, UK, compared joint teleconsultations between GPs, specialists, and patients (virtual outreach) with standard outpatient referral.
Virtual outreach services were established in London and Shrewsbury, UK, ensuring a mix of patients from urban and semi-rural settings. This involved patients and GPs communicating with a specialist using a video-conferencing procedure. Around 2100 patients were randomly assigned to receive either a virtual outreach consultation or a standard outpatient appointment arising from conventional referral by GPs. Patients in both groups were followed up for six months.
Unexpectedly, more patients in the virtual outreach group (52%) than the standard group (41%) were offered a follow-up appointment; this effect varied substantially between hospitals and specialties, probably because of specialists' differing needs to see the patient again in hospital for a direct examination. However, fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per individual, and patients expressed greater satisfaction from virtual outreach consultations compared with standard outpatient appointments.
Paul Wallace comments: "The findings of this trial have important implications for the design and implementation of virtual outreach services within health-care systems, and suggest that appropriate selection of patients, significant service reorganisation and provision of logistical support for arranging and conducting consultations will be required to enable such services to operate efficiently. The extent to which virtual outreach is actually implemented will probably also be dependent on factors such as demand by patients, costs, incentives for general practitioners to allocate additional time to this activity, and the attitudes of staff working in general practice and hospital settings."
In an accompanying Commentary (p 1957), Eivind Rinde from Telenor Research, Tromso, Norway, concludes: "The future of telemedicine depends on wide regular use in the medical areas where telemedicine has been a success and shown to be cost effective-eg, radiology and dermatology. The digitising of medical equipment in, for example, radiotherapy makes it a good candidate for success in telemedicine. Technical and organisational innovation in specialties where telemedicine has been useful may be a driving force for other telemedicine applications."
Contact: Professor Paul Wallace, c/o WHO European Centre for Environment and Health, World Health Organisation, Via Francesco Crispi, 1000187 Rome, Italy; T) +39 347 271 3436 or +39 06 487 7548; F) +39 06 487 7599; E) firstname.lastname@example.org
Dr Eivind Rinde, Telenor Research, PO Box 1156, N9001 Tromso, Norway; T) +47 776 12790; F) +47 776 12702; E) email@example.com