Table 3

Side-by-side joint display 

QuestionnairePatient interviewsConsultant interviewsSummary
Themes/DomainsPatient understanding and expectations
  • 44% recalled receiving written information about the clinic process following the initial contact.

  • 89% of these felt that the information was easy to understand and use.

  • Two patients disagreed, one commenting:

    “the technicalities involved were difficult to understand unless I had some medical knowledge. Needed to look up some details to clarify”

  • 26% of patients reporting having had three or more virtual clinic follow-up appointments (not consistent with the period the pathway had been available).

  • One comment was made:

    “I don’t understand the term ’virtual clinic …. If you use totally different descriptions of the same assessment you will confuse people”

  • All demonstrated a clear understanding that the virtual clinic pathway replaced a face-to-face outpatient appointment, following their joint replacement.

  • All were familiar with the term virtual clinic:

    it is done through X-ray and the clinical outcomes, the survey I did”

  • There was an expectation that consultants were reviewing each PROM as it was completed.

  • There was confusion about the role of the administrator, consultant and secretary. The administrator is seen as someone who resolves the computer and or process issues and the consultant and secretary are as independent of the process only dealing with clinical queries:

    “I see the consultant and his secretary separate, I know that they are connected but I feel that the virtual clinic is something completely different and managed by different people”

  • The effect on workload was not as simple as had been expressed to the patients. For instance, some consultants previously discharged patients at 3 months therefore this new system will increase follow-up workload.

  • Concerns were raised regarding capacity and long-term management. If the virtual clinic pathway reflects the BOA guidance a consultant conducting 200 hip and knee replacements year, assuming no deaths or complications this could result in as many 1000 follow-ups required, each year.

    “It’s a good way of following them up, but I think we are creating a problem for us in the future”

The questionnaire raised concerns that a significant minority were confused by the terminology, highlighting the need for consistency.
While at interview patients were seen to have good understanding of the process.
However, it was revealed that patients did not perceive the administrative and clinical team as a single unit.
The addition of the consultant perspective revealed the virtual clinic rather than simply being a replacement for routine care was actually in some ways an additional service.
Themes/DomainsPatient confidence
  • Clarity of the follow-up report was rated as acceptable by 95% of respondents with 67% rating it as good or higher.

  • One comment was made about the communication received:

    “Very clear and helpful letter.

  • Another comment hinted at lack of confidence in the process:

    “no opportunity to check that everything was as it should be”

  • The patients had confidence on receipt of the letter informing them the consultant had reviewed their scores and X-ray that the process was working.

  • This was further validated by prompt response and confirmation that their general practitioner had been kept informed.

  • All patients found the letter to be informative and gave them the confidence to contact the department should their situation change.

    “the fact he said, ‘If you have a problem, ring my secretary’ was really comforting ….”

  • Confidence in being able to contact the administrator with queries also emerged as important in the interviews.

    “She talked me through it and that was very helpful and I think having a voice on the end of the phone, for that sort of thing, is an excellent idea”

  • Nil directly relevant to topic.

Patients need confidence that the processes are being managed and clinical oversight is in place.
Interestingly it was the timely receipt of the clinic letter/report and the quality of its content that the interviews found as the chief determinant of the patient confidence in the process. It was therefore important that the majority of patients surveyed found the report clear.
However, both aspects also showed that providing alternative contact options for reassurance are imperative.
Themes/DomainsPatient voice
  • Some patients expressed frustration in the free text, one comment said:

    “The tick box ‘black/white’ system left no room for ‘grey’ areas …. We are still people and not machines!” and another

    “It’s one-way”.

  • Only one patient interviewed felt that they had a lack of choice about following the virtual clinic pathway as they reporting being told:

    “there was no need to see the consultant”.

  • Patients saw the PROMs as easy to understand but there were some frustrations in completing them. Some felt that they did not have a voice, the process was didactic, impersonal and lacked flexibility.

    “if you don’t fit into that you are not going to get the appraisal that relates to your problem”

  • There appeared to be a disconnect between the understanding of discomfort and pain. One patient did not recognise the discomfort she was experiencing could be expressed as being as low-level pain. Instead, she felt that the questionnaire was not relevant to her situation.

  • Patients highlighted that in a face-to-face review such uncertainties can easily be addresses:

    “if I had seen the surgeon and he’d asked me those questions, I’d have said, Yes but ….”

  • To rectify this there was a strong desire for an MCO comments box to explain a response.

  • Patients who had other joint replacements wanted to communicate progress concerning these and the inability to do so using the system caused frustration. For instance, one patient reported that he was following the virtual clinic pathway for one hip replacement but was experiencing a problem with his previous hip replacement conducted by a different consultant.

  • The arrangement worked really well for those patients who remained trouble free and they liked the straight-forward, ‘click and go approach’.

  • Nil directly relevant to topic.

Patients were recruited by various methods: email, telephone call or by post.
Some comments in the questionnaire hinted at frustration with communication. Exploring this further at interview it seemed that this could largely be addressed by offering a comments box or alternative method of contact so that patients could communicate their uncertainties.
Themes/DomainsManaging deterioration of condition
  • Four (9%) respondents indicated that they felt their joint replacement was being followed up ineffectively.

  • Two words that had relatively high frequency in the free text of the questionnaire were problems (n=28), questions (n=24) and issues (n=19).

  • The patients acknowledged and demonstrated self-management opportunities within the virtual clinic process.

  • The tracking of scores over time graphically demonstrated progress or deterioration, thus enabling the patient to manage their physical condition, such as increasing pain medication or seeking physiotherapy support.

  • Patients expected that if the scores were deteriorating over time this would be picked up by the consultant between virtual clinic appointments.

  • There was some uncertainty how to report deterioration with some people unsure who to contact.

  • The two patients fully cognisant of the pathway had both worked in healthcare.

  • Nil directly relevant to topic.

Although some patients used the scores as an opportunity for self-management, there was a mislead expectation that if the scores were deteriorating over time this would be picked up by the consultant automatically (between virtual clinic appointments).
It is important that patients are informed what action to take in the case of deterioration.
Themes/DomainsPatient benefit
  • Radiographs were obtained widely across the county and 98% reported the scheduling as convenient.

  • Most patients (91%) indicated the ease of setting up the follow-up appointment was either very good or good.

  • Free text comments commonly included the words: time (n=97), saves (n=56), easy (n=27), money (n=24) and travel (n=22) suggesting such concerns/benefits were important to patients.

  • 86% of respondents indicated they had made financial savings with the most frequently attributed category being travel costs (39%).

  • One patient commented: “It saved the time of travelling to and waiting at the hospital”

  • Practical and personal benefits were reported. The process appeared time saving by reducing travelling distance, time taken off work and not having to wait to see a consultant in the outpatient department in addition to the availability of local X-ray seen in the questionnaire.

  • The patients found the service to be convenient and enabled them to complete the PROMs at their own convenience.

  • Some experienced a financial benefit through cost savings in fuel, transport, meals and parking fees.

    “Well, it’s probably half to three quarters of an hour each way and then you have got to pay for parking, haven’t you? It’s a chunk of your day, isn’t it?”

  • Patients also found it helpful and motivating to see their progress in the graph enabling them to self-manage their condition:

    “I found it really interesting because when I first went on it was before the operation so it would have been very low then, just to see it jump right up after the operation, … It went down slightly but then I thought it might because I was in a bit more pain then. I just took some tablets”.

  • Consultants perceived considerable benefits for the patients’ convenience and being able to monitor their own progress.

  • They also drew a comparison with routine care sitting the new pathway as an improvement:

    “I think they probably get a better long-term follow-up than we do at present because at present at 6 months or a year they are discharged”.

The questionnaire demonstrated the expected changes of patients choosing to use peripheral hospitals to have their radiographs. The process was reported as straight forward and both time and money saving. These findings were confirmed at interview.
However, the it was only in the interviews that the benefit of self-management became evident.
A further element was commented on by the consultants in that the follow-up would be available more long term than previously.
Themes/DomainsPatient satisfaction
  • When asked to compare the care received via the virtual clinic with a face-to-face appointment, 59% did not express an opinion either way, 21% of people rated this as worse and 21% rated it as better.

  • Free text answers suggested quite polarised views:

    “I did not receive care at all” verses:

    “Easy to follow and no concerns”.

  • 9% of patients surveyed felt that their joint replacement was not being followed-up effectively. With 12% feeling that they would be less likely to comply with the virtual clinic process than attend a face-to-face consultation.

  • Satisfaction depended on whether the process had worked for them and on delivery of person-centred care.

  • From a functional point of view, such as using the computer and attending a local hospital for an X-ray, the system rated very highly.

  • Even if computer problems existed, the way they were managed by the administrator was highly satisfactory to all.

  • There was a comment of mild irritation when a problem needed to be resolved via the MCO website, such as password resets, as patients had to wait between 24 and 48 hours for a response.

  • Patients who were doing well, appreciated the ‘click and go’ aspect that the virtual clinic offered. When asked how they rated the system:

    “Oh 100%, 100%”

  • Several expressed a sense of satisfaction of being able to give something back to the system, in particular, acknowledging that the virtual clinic was freeing up the consultant’s time to see those in need.

  • Patients experiencing a concern were less satisfied with the removal of the personal face-to-face interaction:

    “People who are following up, mustn’t persuade themselves they’ve got a patient now who is wholly satisfied”

  • Nil directly relevant to topic.

The questionnaire had unearthed quite diverse opinions about whether the virtual clinic was better or worse than having a face-to face consultation. Exploring this in the interviews it depended how well the process had worked for them and whether they were worried about their joint that caused this division.
Interestingly some were relatively altruistic wanting the consultants to spend time with those in need.
Themes/DomainsUsing technology and navigating the website
  • The majority (93%) accessed the website at home.

  • Comparing the virtual clinic to a face-to-face appointment 70% found it an easier process, while 9% found it harder.

  • It took 70% of patients less than 10 min to register online and complete their assessments and no one took longer than 20 min.

  • 100% of patients gave a neutral or positive response when asked about the usability of the website.

  • All interviewees were comfortable and competent users of technology.

  • Some of the patients have expectations that in future the NHS will use more technology.

    “Brilliant idea”

  • Most found the website easy to navigate to complete their scores.

  • There were minor difficulties logging in, which were resolved.

  • The patients appreciated the update reminders telling them they needed to complete their next score. They also all liked having the personal feedback, via the graphs, over time.

  • One person would have liked to receive an acknowledgement from the website of a change in the scores but instead just got a generic thank you message.

  • One patient raised her concerns over security in general but not relating to this website specifically.

  • Patients are screened by clinicians and the administrator considering frailty, access to technology, computer skills and compatibility of internet browsers with the MCO platform. It was felt that more elderly patients were less likely to be suitable for virtual clinics.

    “A lot of patients are over 80. Some of them are absolutely fantastic and do it but they’re a minority”.

  • The perceived proportion of patients suitable for virtual clinic was approximately 10%.

  • Despite this relatively low proportion it was a believed that this number was now rising as more people are becoming computer literate.

  • Concerns were raised around patients who needing assistance with using MCO. Perceived problems were the ethical questions of confidentiality (though necessitating third parties having access to the information) and that reporting may not be reliable:

    “Friends doing it, again, it’s done once and it’s never updated”.

Most patients were able to access the web from home and many found the virtual process easier than attending a traditional clinic. The patient interviews pointed to specific technical difficulties and were generally positive about the technology. However, the consultant interview highlighted the need for appropriate patient selection and perception that this pathway is suitable only so a specific sub population of those undergoing joint replacement.
  • BOA, British Orthopaedic Association; MCO, My Clinical Outcomes; NHS, National Health Service; PROM, patient reported outcome measures.