The Digital Skills Gap Exposed by COVID-19 Must be Closed to Improve Remote Clinical Services and to Protect Patients

This article was first published in The Journal of mHealth

Digital technology has transformed the way that patients can interact with clinicians around the world through remote, virtual clinical services often delivered through personal mobile devices. Virtual health services have made it possible for geographically remote patients to access care; for clinicians to reach underserved populations; and for primary and secondary care services to be delivered during a global pandemic where the key phrase has been “social distance”. The Lancet reported that uptake of video consultation platforms had increased 1000% in the space of 2 weeks in late March 2020.

However, in all industries, the sudden onset of technology innovation driven by the pandemic has exposed gaps in digital skills literacy. Training and digital learning programmes that would have previously taken months or years have been accelerated to days or even hours.

In a clinical setting, this digital skills gap is even more significant. Doctors spend years in medical school and in face-to-face clinical environments learning to practice medicine and, in most cases, will have received no formal training in video consulting. Further, Roger Neighbour’s 2005 book, The Inner Consultation – how to develop an effective and intuitive consulting style [1], points to a whole host of non-verbal indicators to a patient’s wellbeing that a consulting physician should be attuned to. Over a voice call, or even a video call with poor quality video, it can be difficult or impossible to pick up on these indicators. And, this is even before they are faced with the distractions of non-functioning IT or technical device trouble-shooting they have never been trained to resolve.

Physicians who cannot access digital skills training will likely take longer to access and use new technologies, removing the efficiency benefits obtained from the technology in the first place. In extreme instances, this lack of training can lead to missed diagnoses; a lowering of trust in the doctor-patient relationship; and, potentially, patient harm.

Only by closing the underlying digital skills gap will patients and doctors be able to access the full benefits of these new digital technologies.

Firstly, recognise and adopt the physical environment in a digital world to ease transition

Termed “skeuomorphism”, we see many new digital technology products make themselves relatable by mimicking real world counterparts. Icons and concepts like the trash can or folders on your desktop provide contextual meaning even when the physical equivalents are long retired. The same applies in clinical practice, and is a helpful initial step to shrinking the skills gap.

For example, physical concepts like the “waiting room” or the “consultation room” provide important functions in the real world that are not strictly necessary in a digital world – you no longer need to provide a place to stand or sit when patients are at the end of a mobile device in their own home. However, this physical separation supports the inherent queuing mechanisms that ensure optimal efficiency of a clinician’s time. Patients and clinicians alike look for these physical equivalents to ease this transition to a digital world.

In our recent work, supporting the uptake of virtual consultation platforms in the National Health Service in England, we found that many corporate video conferencing tools were designed on the assumption that all participants can schedule a specific time. Conversely, physical clinic waiting rooms operate on a continual flow basis in the real world. By introducing digital concepts like virtual waiting rooms and a digital reception and “check-in” procedure we made the adoption of these digital tools easier for patients and clinicians alike.

The introduction of digital equivalents to common physical paradigms can ease the operational digital skills transition – and, in the case above, was scaled to support over 1 million virtual consultations a year.

Then, recognise the technical limitations and re-plan clinical services around them

We’ve seen many exciting technology developments in recent years that put advanced diagnostic tools in the hands of patients at home – from heart-rate monitors embedded on smart watches through to low-cost mobile camera attachments to support ophthalmology and algorithms that can detect breathing anomalies from a mobile microphone. However, to fully adopt these technologies, clinicians need technical training on everything from instrument calibration through to connectivity troubleshooting.

Further, some clinical services that initially appear ideal for virtual or video consultation because they do not require diagnostic machines or physical contact are in fact not feasible using the consumer grade technologies available in a patient’s home.

Learning from a pre-pandemic project standing up a Virtual Health Services business for Catholic Health Initiative (now CommonSpirit Health) – dermatology was frequently cited as a potential candidate for remote consultation. However, in reality, cameras on mobile devices or web cams at the time did not provide the resolution required to make advanced diagnoses. Even now, reliably configuring a remote consultation accounting for variations in lighting, camera positioning, and low bandwidth video resolution can still make diagnosis a challenge.

As with any new technology, clinical practice must adapt. But to adapt, clinicians need the skills, experience and knowledge to know what works and what doesn’t – picking the best parts of the new technology and weaving it seamlessly into patient care pathways for better outcomes and better patient experience.

Finally, build digital skills through a core curriculum in continuing education as well as embedded learning in the workplace

The steps above are important and necessary but only provide a short-term boost to digital skills improvement. And, in each case, the actions above can actually have the adverse effect of overriding the improved patient experience possible with remote care.

The long-term success of mHealth and remote care certainly rests on the ability of medical education establishments to provide the skills needed in the primary and secondary care workforce. The American Medical Association highlighted the need for undergraduate telemedicine courses as far back as 2016 and identified 32 US medical schools to establish formal course materials. And, in the last year, University College London has launched a free course on how to run Remote Consultations and Triage in response to the COVID-19 pandemic.

This formal medical education is welcome and will embed a strong knowledge base in the profession. However, we’d go further to recommend a broader application of digital skills development for clinical and non-clinical staff in the workplace. This could take the form of enhanced information and instruction at the point-of-care or bite-sized skills training sessions delivered by care providers – taken a step further it may even involve augmented reality training programmes delivered alongside physical training programmes.

Ultimately though, closing a digital skills gap will require an underlying shift in attitudes, expectations and culture – recognising that digital skills are important in ensuring the end-to-end remote clinical experience is as safe and complete as it can be.