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. 2024 Sep 18:10:e46485.
doi: 10.2196/46485.

The Use of Online Consultation Systems or Remote Consulting in England Characterized Through the Primary Care Health Records of 53 Million People in the OpenSAFELY Platform: Retrospective Cohort Study

Martina Fonseca  1 , Brian MacKenna  1   2 , Amir Mehrkar  2 ; OpenSAFELY Collaborative  3 ; Caroline E Walters  2 , George Hickman  2 , Jonathan Pearson  1 , Louis Fisher  2 , Peter Inglesby  2 , Seb Bacon  2 , Simon Davy  2 , William Hulme  2 , Ben Goldacre  2 , Ofra Koffman  1 , Minal Bakhai  1
Affiliations

The Use of Online Consultation Systems or Remote Consulting in England Characterized Through the Primary Care Health Records of 53 Million People in the OpenSAFELY Platform: Retrospective Cohort Study

Martina Fonseca et al. JMIR Public Health Surveill. .

Abstract

Background: The National Health Service (NHS) Long Term Plan, published in 2019, committed to ensuring that every patient in England has the right to digital-first primary care by 2023-2024. The COVID-19 pandemic and infection prevention and control measures accelerated work by the NHS to enable and stimulate the use of online consultation (OC) systems across all practices for improved access to primary care.

Objective: We aimed to explore general practice coding activity associated with the use of OC systems in terms of trends, COVID-19 effect, variation, and quality.

Methods: With the approval of NHS England, the OpenSAFELY platform was used to query and analyze the in situ electronic health records of suppliers The Phoenix Partnership (TPP) and Egton Medical Information Systems, covering >53 million patients in >6400 practices, mainly in 2019-2020. Systematized Medical Nomenclature for Medicine-Clinical Terminology (SNOMED-CT) codes relevant to OC systems and written OCs were identified including eConsultation. Events were described by volumes and population rates, practice coverage, and trends before and after the COVID-19 pandemic. Variation was characterized among practices, by sociodemographics, and by clinical history of long-term conditions.

Results: Overall, 3,550,762 relevant coding events were found in practices using TPP, with the code eConsultation detected in 84.56% (2157/2551) of practices. Activity related to digital forms of interaction increased rapidly from March 2020, the onset of the pandemic; namely, in the second half of 2020, >9 monthly eConsultation coding events per 1000 registered population were registered compared to <1 a year prior. However, we found large variations among regions and practices: December 2020 saw the median practice have 0.9 coded instances per 1000 population compared to at least 36 for the highest decile of practices. On sociodemographics, the TPP cohort with OC instances, when compared (univariate analysis) to the cohort with general practitioner consultations, was more predominantly female (661,235/1,087,919, 60.78% vs 9,172,833/17,166,765, 53.43%), aged 18 to 40 years (349,162/1,080,589, 32.31% vs 4,295,711/17,000,942, 25.27%), White (730,389/1,087,919, 67.14% vs 10,887,858/17,166,765, 63.42%), and less deprived (167,889/1,068,887, 15.71% vs 3,376,403/16,867,074, 20.02%). Looking at the eConsultation code through multivariate analysis, it was more commonly recorded among patients with a history of asthma (adjusted odds ratio [aOR] 1.131, 95% CI 1.124-1.137), depression (aOR 1.144, 95% CI 1.138-1.151), or atrial fibrillation (aOR 1.119, 95% CI 1.099-1.139) when compared to other patients with general practitioner consultations, adjusted for long-term conditions, age, and gender.

Conclusions: We successfully queried general practice coding activity relevant to the use of OC systems, showing increased adoption and key areas of variation during the pandemic at both sociodemographic and clinical levels. The work can be expanded to support monitoring of coding quality and underlying activity. This study suggests that large-scale impact evaluation studies can be implemented within the OpenSAFELY platform, namely looking at patient outcomes.

Keywords: OpenSAFELY; digital primary care; electronic health record coding; general practice; health informatics; online consultation system; primary care research; remote monitoring; triage; trusted research environment.

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Conflict of interest statement

Conflicts of Interest: BG has received research funding from the Laura and John Arnold Foundation, the Bennett Foundation, the National Health Service National Institute for Health and Care Research (NIHR), the NIHR School for Primary Care Research, the NIHR Oxford Biomedical Research Centre, the Mohn-Westlake Foundation, NIHR Applied Research Collaboration Oxford and Thames Valley, the Wellcome Trust, the Good Thinking Foundation, Health Data Research UK, the Health Foundation, the World Health Organization, UK Research and Innovation, Asthma UK, the British Lung Foundation, and the Longitudinal Health and Wellbeing National Core Study and Wellbeing strand of the National Core Studies program; he also receives personal income from speaking and writing for lay audiences on the misuse of science. All Bennett Institute for Applied Data Science staff are supported by BG’s grants received for this work. BMK is employed by National Health Service England working on medicines policy and as clinical lead for primary care medicines data. AM has represented the Royal College of General Practitioners in the health informatics group and the profession advisory group that advises on access to GP Data for Pandemic Planning and Research; the latter is a paid role. He is a former employee and interim chief medical officer of National Health Service Digital (now merged into National Health Service England). He has consulted for health care vendors, the last time in 2022; the companies he has consulted with in the last 5 years have no relationship to OpenSAFELY or this study. All other authors declare no other conflicts of interest.

Figures

Figure 1
Figure 1
(A) Absolute weekly online consultation (OC) code instances in The Phoenix Partnership (TPP) system (source: OpenSAFELY-TPP). (B) Weekly OC submissions for practices that have TPP as the main general practitioner system (source: national rapid collection). Between 66 and 132 practices each week had no clear system associated in the patient web-based management information data collection and were not included.
Figure 2
Figure 2
Portion of The Phoenix Partnership (TPP) practices with any recorded activity for online consultation–relevant codes (January 2019-December 2020). Codes with no activity at all have been omitted.
Figure 3
Figure 3
Monthly code instance rates per 1000 registered practice patient population of Systematized Medical Nomenclature for Medicine–Clinical Terminology (SNOMED CT) codes in The Phoenix Partnership (TPP) general practice (January 2019-December 2020). March 2020 data are indicated in pink. (A) General practitioner consultations, with.gp.consultations(). (B) Encounter by computer link, 185320006. (C) Email sent to patient, 401271004. (D) Alert received from telehealth monitoring system, 699249000. (E) eConsultation via web-based application, 1068881000000101. (F) Remote consultation encounter type, 325871000000103. (G) Telemedicine consultation with patient, 448337001.
Figure 4
Figure 4
Contextual information. Recording of results from general practice consultations (any modality) in general practice (January 2019-December 2020). IDR: interdecile range.
Figure 5
Figure 5
Recording of results from eConsultation via online application (“1068881000000101” - “Y1f3b”) in general practice (January 2019-December 2020). The top 4 deciles can be discerned, with the top practice decile peaking at approximately 30 events per 1000 patients. The lowest 4 deciles of practices have very low rates, which is why they cannot be easily discerned. IDR: interdecile range.
Figure 6
Figure 6
Recording of results from telemedicine consultation with patient (“448337001” “XaXcK”) in general practice (January 2019-December 2020). The top 4 deciles can be discerned, with the top practice decile peaking at >1.5 events per 1000 patients. The lowest 4 deciles of practices have very low rates, which is why they cannot be easily discerned. IDR: interdecile range.
Figure 7
Figure 7
Recording of results from any of the short-listed Systematized Medical Nomenclature for Medicine–Clinical Terminology (SNOMED CT) online consultation codes in general practice (January 2019-December 2020). Logarithmic scale: the top practice decile peaks at >36 events per 1000 patients.
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References

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