DECODE: Exploring the unintended consequences of digital health tools

Primary care is facing a workforce crisis and ever greater demand from patients. Policymakers see digital health tools, including alternatives to face-to-face consultations and access to electronic medical records, as a potential solution to growing demand.

NHS England required all GP practices to provide online consultations – where patients submit their symptoms via an online form – since April 2020. Online consultations were promoted as a solution to improve access to primary care and reduce GP practice workload. The COVID-19 pandemic has accelerated their use in England.

Since April 2019, NHS patients have had the right to access their electronic medical records created after this date, with full, retrospective access since April 2020. This is intended to enable patients to take greater control of their healthcare and make care more efficient.

This increase in the use of digital health tools could lead to unexpected consequences, both positive and negative. Understanding their impact is vital to minimise negative effects and harness the positives, to improve their use in the future.

This project was a collaboration between ARC West, the Centre for Academic Primary Care at the University of Bristol, and the Universities of Manchester, Oxford, Warwick and UCL.

Project aims
To understand the consequences of using digital health tools in primary care, we:

- reviewed the existing research on the unintended consequences of digital health tools
- interviewed patients, GPs and practice staff on their perceptions and experiences of digital health
- carried out workshops with the groups above
- developed case studies on online GP consultations and online patient access to medical records

Online consultations
For some patients, online consultations improved access to care and were convenient. This was particularly the case for patients who felt they could express themselves better in writing. Some patients valued submitting enquiries at their own convenience and for simple enquiries that didn’t warrant a face-to-face appointment.

However, online consultations made it difficult for some patients to communicate effectively with a GP. The structured questionnaires used in some systems were hard work for simple enquiries. When patients were allowed to write freely, some struggled to explain their issue. Patients weren’t sure if they were writing to their own GP or someone else and had concerns of who would read their enquiry.

To ensure patients with limited IT access or skills could still access care, some practices allowed staff to complete an online consultation form for them, over the phone or in person. However, this was time consuming for staff and could compromise patient confidentiality.

For some GPs, online consultations were valued for giving greater flexibility in managing patient care and staff working patterns. However, for others online consultations generated additional work and led to staff dissatisfaction. Poor quality or incomplete information meant patients needed to be followed up with a telephone or face-to-face consultation, which could duplicate work. Some GPs felt that spending more time in front of a computer processing enquiries resulted in ‘call-centre medicine’ which was tiring and isolating, and meant less time physically seeing patients.

Online patient access to health records
Online access to health records could have negative unintended consequences for:
- Patient autonomy
- How GPs document things in a patient’s record
- GP practice workload

Online access negatively impacted patients’ control over and understanding of their health. For example, if patients discovered information that was surprising or difficult to interpret.

It also impacted how GPs documented things. Sometimes, this could help patients, such as when GPs tried to avoid potential misunderstandings. In other cases, it negatively impacted the quality of the record if GPs avoided documenting their speculations or concerns. This could have legal and patient safety consequences.

Contrary to assumptions that practice workload would be reduced, online access introduced extra work. This included managing and monitoring access and trying to prevent possible harm to patients.

Our study shows that, to have the desired effects set out in NHS policy, work is needed to prepare records for sharing and patients about what to expect.

In many cases the unintended consequences of using these tools are foreseeable and can be, at least partly, avoided. However, avoiding unintended consequences requires funding and planning.