Digitally-Enabled Primary Care: A Case For Evolution, Not Revolution

28 June 2021
Primary care covers a wide variety of health needs, types of patients, and care processes and increasingly involves multidisciplinary teams. Making the best use of digital health requires careful consideration of all of these factors, as well as the technologies themselves. Research and experience of digitally-enabled care prior to and during the pandemic have revealed a number of insights which can help to inform future practice, as well as raising new questions in need of attention.

Building on the status quo

Many digital health innovations are already available in primary care, although the extent to which they are used varies widely, both within and across countries. A key example is electronic health record systems, which integrate patient notes, clinical coding schemes, guidelines, decision support tools, e-prescribing and e-referral, alongside other features. The coronavirus pandemic has emphasized the importance of such information systems for safe, accurate, effective and coordinated care, including at the intersection between primary care and public health. Patient portals and related apps are increasingly being used in primary care for appointment booking, ordering repeat medications and viewing test results. Still, patient access to detailed health records has dragged in Europe, despite repeated policy targets. More opportunities for patients to view their medical notes and contribute personal health observations or device readings would help to improve empowerment and collaborative care for those undergoing treatment. At the same time, such systems could provide more accessible and cheaper ways to download relevant documentation when required for work, insurance or travel. For example, the UK’s NHS App now features a vaccine certification module with print capabilities, which is likely to encourage many more citizens to adopt this portal technology in the coming months. Simpler digital methods include appointment reminders, sent via text message, which can help to reduce ‘no shows’, and check-in kiosks in reception areas which can save administrative time. During Covid-19, mobile phone check-ins may also help minimize the time spent in shared waiting rooms, increasing both efficiency and patient safety, given the risks of airborne transmission. Email and secure messaging systems can be useful for primary care patients seeking written health advice or clarification of medication or treatment plans. They may help to quickly differentiate the ‘worried well’ from those requiring physical assessment. Wide variation in the use of email consultation has been reported across countries; however, and in Europe, overall levels of usage remain low. The pandemic appears to have done little to change this. Concerns about workload, legality and patient safety have often been cited as barriers, although emerging evidence suggests that these may be ill-founded. New policies aimed at ensuring that doctors can be reimbursed for email consultations have been introduced in many countries, but this has had mixed success in changing practice. Experience of remote or virtual consulting has been growing over the last 20 years. While fears over losing the human touch have dampened enthusiasm in primary care, trials have shown it to be effective for some patient groups.  The pandemic has provided the catalyst needed to propel this into routine practice, and there is huge optimism about its ongoing use. Recent experience at scale has yielded several lessons, however. On the one hand, adaptation to remote consulting has been easier than expected, helping to alter perceptions. On the other hand, video-conferencing has proven less necessary or desirable than had previously been assumed, with telephone communication being equally or more acceptable in many cases.  As such, the rush of new digital providers into the telehealth market may be creating unnecessary demands and costs, which call for more standards, regulations and guidelines. Other forms of primary care telehealth are also coming into their own, with clinical guidelines now recommending self-management using well-calibrated home monitoring devices, alongside usual care, for patients with long-term conditions like asthma and hypertension.

Emerging innovations

Looking to the future, we can increasingly expect to see first-line queries triaged by chatbots, with or without Artificial Intelligence, which may direct the patient to self-care advice or refer them to a clinician, depending on the answers to successive questions. As the accuracy and safety of these tools are still in question, the risk threshold for triggering human intervention needs to be fairly low, thus introducing such technologies may potentially add, rather than reduce clinical time pressures at this stage. Wearables create similar dilemmas. On the one hand, they provide more ambulatory data and give more freedom to the patient. On the other hand, they can pose greater responsibility for clinicians to monitor this data – if used as part of a supported care plan. Continuous monitoring may also increase the frequency of symptom readings that trigger human interventions or emergency room visits, in a way that would not have happened before. While some wearables are routinely used and their data easily interpreted by primary care physicians – as with ambulatory blood pressure monitoring – as wearables begin to offer a wider smorgasbord of health readings, the volume and complexity of this data are likely to be problematic without the introduction of user-friendly and clinically accurate multi-parameter dashboards, which call for further standards to ensure safety and cost-effectiveness. Other innovations likely to impact primary care include portable screening devices and smartphone diagnostics, which have potential to improve efficiency, by quickly surfacing clinical insights previously only measurable in specialist facilities. The integration of machine learning and artificial intelligence into clinical software and apps could also help optimize and personalize treatments. However, it will be essential for clinicians to recognize the potential for bias and harm when using these technologies, and ensure they have been appropriately tested, regulated and approved. They also need to recognize that algorithms, even if technically robust, may be fed by data or evidence which is flawed, incomplete, unrepresentative or outdated. As such, the continued need for sound clinical judgment cannot be understated. Likewise, using voice assistants in the consulting room could potentially offer advantages over keyboards for reducing infection risks or automating clinical documentation. However, these technologies are still far away from being normalised in primary care and raise similar safety and privacy challenges.

Work, organisation and value

The structure of primary care work is also changing around the world, with single-handed practitioners increasingly joining collaborative partnerships and even multi-specialty primary care centers, in places where the population is large enough to sustain them. In Scotland, for example, some such centers are able to offer a much wider range of services, including mental health and minor surgery, using technology-supported patient triage to direct patients to the most appropriate and cost-effective service for their health issue, thus freeing-up doctors’ time for cases in greatest need of medical assessment or treatment.  While such approaches may not be feasible in many settings, in a future pandemic, it might be possible to rapidly assemble and deliver them virtually, using the right digital platforms and agreements. Despite the attractions of ‘smarter’ services, health service planners must be careful to avoid technocentric over-optimism, which neglects the therapeutic value of clinical relationships and care continuity.  Having a known family doctor who can not only access the patient’s digital record but also has an informal knowledge of their health history, needs and circumstances, offers considerable advantages in primary care. For example, it may provide more context for symptom interpretation, empathy for understanding barriers to treatment compliance, and a trusted environment for sharing health concerns or debunking misinformation, as we have seen so much of during the coronavirus ‘infodemic.’ While digital hand-off to any suitably qualified practitioner may be safe and acceptable for patients presenting with minor acute illness, for those with complex needs or the elderly, this is likely to be a false economy. Wholesale conversion to virtual consulting in primary care is also ill-advised. Patients may have difficulties articulating their symptoms at a distance, and clinic-based follow-up and testing will be needed to avoid the risks of harm from undiagnosed disease, particularly in health systems where specialist medicine is accessed via primary care referrals.  Even one case of a patient dying after a failure to escalate from remote to in-person consulting can attract intense media criticism, which can hobble legitimate telehealth services, calling for high levels of vigilance. Experience of remote telemonitoring in primary care has also revealed the importance of initial training for patients and professionals, to gain the most value for patient health and avoid expensive or dangerous errors.  Managers should factor this into their cost-calculations and not assume a plug-and-play model will work.

The role of health systems 

It is not possible to consider the future of digital primary care without considering the broader health systems in which this is taking place.  Although Universal Health Coverage is regarded as the gold standard, many countries still rely on a combination of government and self-funded primary care, whether out-of-pocket or via private insurance. Digital health can create opportunities for patients to manage their health more affordably by encouraging preventive lifestyle changes, facilitating disease self-management, and lowering the direct and indirect costs of clinic visits, travel or unpaid time off work. Even in countries with free access to primary care, such as the UK, new businesses offering to deliver private video-consulting services and rapid appointments are proliferating. While these offer speed and convenience for patients with the money to pay, they also increase existing health inequalities and risk eroding the state-funded primary care workforce. It may also tempt some governments to nudge patients towards paying twice for their care – once through their taxes and once from their taxed salaries, which creates unfairness even for those with the most resources.
The trust can be particularly fragile when commercial actors are involved
Primary care is a luxury that people in many countries can’t easily obtain, either because there are too few doctors, or communities are too remote and widespread to sustain local health facilities.  For this reason, the value proposition for remote or computer-driven primary care may be greater in these regions. For example, using smartphone protocols to augment the skills of a community health worker may provide a ‘virtual’ nurse or doctor in physical form, while chatbots or simpler mobile phone question-answering tools may significantly improve preventive and self-care. Inter- and intra-regional variation in the maturity of digital primary care is a key consideration, of course. While in some countries, like the UK, practices have been ‘paperless’ for many years, elsewhere pockets of resistance can be seen. Often this has less to do with money than entrenched professional cultures, the absence of a strategy for primary care computing, or multiple public/private sector models that have hindered standardization. Nonetheless, with the massive incentive schemes seen in the US and Europe over the last decade and changing workforce demographics, the remaining digital desert islands are likely to disappear soon.

Data and control

A number of countries are beginning to automate the extraction of patient data from primary care systems into centralized digital platforms to support planning, research, public health and innovation. This could yield improvements in healthcare efficiency, quality, treatments, disease prevention and outcomes. Still, it also creates significant privacy and security risks, which have not yet been fully put to the test and, if mishandled, could damage public trust. This trust can be particularly fragile when commercial actors are involved, as has been seen in debates over the role of global technology giants during the pandemic response. Meaningful public consultation, appropriate anonymization, opt-out mechanisms, strong security and regulatory oversight will all be needed to ensure that these uses of patient information are acceptable, safe, proportionate, fair and legal.  This is relevant to primary care practice, not only because of the type of rich data involved but also because many patients believe their trusted family doctor has control over decisions about how their health information may be re-used, which is increasingly no longer the case, creating room for tension in the clinical relationship.  It may also disempower primary care doctors who have previously had greater control over their patients’ information, although this can be balanced through reciprocal data reports that can help to improve patient care. Aside from such major programs, which are often directed by governments, the data generated through the use of digital technologies in primary care is also being mediated by a plethora of businesses, such as providers of software, devices, apps and cloud hosting services, whose information governance processes can be hard to fathom. As the use of digital tools in primary care grows, so will the need for clinicians and managers to ensure suppliers are adhering with relevant privacy and security requirements. Being able to rely on a trusted, standardized, verified and accountable digital health ecosystem will help to reduce this burden. Still, such collaborative enterprises also need effective governance, and not only by the industry itself.

Understanding patients and communities

Just as with primary care professionals and organizations, the patients and communities they serve can vary widely in terms of their readiness for digital change.  Moreover, patient characteristics, circumstances and preferences can influence the value that can be obtained from different digital health approaches. Patients who are already familiar with video consulting may benefit more from this medium. For example, while email consulting may offer welcome time-saving for young working professionals but may leave the elderly disempowered and under-treated. Similarly, while access to detailed health records can offer benefits for some patients, it could also be misused by coercive actors or unintentionally betray the confidentiality of third parties, calling for careful conversations with patients at risk and appropriate data redaction efforts. Long-standing social inequalities in health status, health literacy and health empowerment are also manifested in the ‘digital health divide,’ whereby those with the means to access and use these new opportunities can further enhance their health, whilst those without may fall further behind. As the frontline of medicine, primary care needs to pay special attention to digital inclusion. Cheap and accessible approaches, like telephone, SMS text messaging and print may be preferable to sophisticated smartphone apps for reaching low-income communities. In many cases, they are just as effective. As digital gradually becomes the default mode for informing or supporting patients between-clinic visits, innovations such as social prescribing may be necessary to ensure that those who need them are provided with the essential tools and training. So-called Health 2.0 has impacted primary care since the dawn of the Internet, with greater access to online health information enabling patients to have more informed discussions with their doctors and opportunities for clinicians to direct patients to sources of further reading. Some concerns about the clinical time needed to correct misunderstandings about evidence or treatments have previously been expressed. However, the dramatic rise of social media misinformation during the pandemic suggests that new training and skills in infodemic management will be needed if primary care is to remain practically manageable and maintain mutual trust and respect in the therapeutic encounter. Understanding people’s personal circumstances and attitudes is not only vital for ensuring the appropriate use of alternative methods but can also be critical for their effective design. Observations about preferences for telephone over video consulting in the pandemic echo experiences from previous waves of telehealth enthusiasm, which foundered on a lack of understanding of patient needs and primary care workflow, leading to poor design decisions, including intrusive technologies or unrealistic expectations for clinician monitoring.

Moving forward

As we move beyond the pandemic, new norms around digitally-augmented and collaborative medicine are likely to develop, reflecting both generational and technological trends. Still, human primary care will remain a vital requirement for effective, fair and sustainable health systems. Unresolved challenges around privacy, patient safety, equity, rights, empathy and trust, call for more attention to be paid to the unique ethical challenges of digital health in primary care and new guidelines, tailored to this specific context, may be advisable. Digital transformation in primary care has occurred in incremental steps, but remarkable progress has been achieved over time. Experiences gained during the pandemic have proven useful for encouraging digital adoption, altering mindsets and learning lessons. Still, given the complexities involved, further progress is likely to be gained through an ongoing process of evolution and adaptation rather than revolution and disruption.