Title: Enhancing technology-mediated communication: qualitative analysis of remote consultations in cancer, diabetes and heart failure
Funder: Department of Health and Social Care

Abstract: BACKGROUND Remote video consulting is promoted by policymakers as a way of delivering healthcare efficiently to an ageing population with rising rates of chronic illness. As a radically new service model, it also brings operational and interactional challenges in using digital technologies. For this reason, in-depth research on this dynamic is needed before remote consultations are introduced more widely. To date, little research has been done examining the fine-grained detail of how remote consultations unfold. Insights are needed to inform and support patients and clinicians who want to use this technology when consulting. There is extensive evidence focusing on communication and interaction in medical consultations. However, evidence from studies beyond the medical literature highlighting the ways in which SkypeTM and similar media might alter interaction (e.g. de-synchronising communication) has yet to be considered in relation to remote consultations. To our knowledge, no previous high-quality qualitative studies of communication in remote consultations have been conducted. In sum, there is a significant knowledge gap in relation to the fine detail of communication in remote consultations. AIMS To identify and analyse the communication strategies through which remote consultations are accomplished; and to produce guidance to inform clinicians and patients on the future use of remote consultations. DESIGN Secondary analysis of a combined dataset of 37 video-recorded remote consultations (using SkypeTM and FaceTimeTM) and 16 comparable face-to-face consultations in diabetes, cancer and heart disease services. Remote consultations were undertaken by senior and junior doctors and nurse specialists in services in East London and Oxford, consulting with young people aged 16-25 with diabetes, women who have diabetes in pregnancy, older people consulting for post-operative cancer surgery and community-based patients having routine heart failure reviews. All of the remote consultations in our dataset have been transcribed (capturing verbal and non-verbal detail) and analysed within two previous studies. This (largely quantitative) analysis has allowed us to identify subtle changes in the ways in which patients and clinicians interact in face-to-face and remote consultations, including potentially significant differences in, for instance, verbal attentiveness and sharing information. The exact reasons for these differences remain unclear. We plan detailed qualitative analysis (informed by ethnography of communication and discourse analysis) of verbal and non-verbal communication between clinicians and patients to explain these differences. PLAN OF INVESTIGATION We will examine the contextual features in remote consultations (e.g. restricted visual field), combined with close analysis of different modes of communication (e.g. speech, gesture, gaze). We will draw on established techniques for close analysis of face-to-face and telephone conversation, and insights from recent work on mediated and multi-modal interaction using verbal and visual channels (e.g. video-conferencing). Analysis will be iterative focusing on, for instance, opening sequences (where our earlier analysis has shown that there is often discussion about the technology in remote consultations), management of turn-taking (which may be affected by the way technology constrains participants visual orientation to each other); displays of active listening (verbal and nonverbal); interruptions and repair (how participants deal with interactional problems, including where the source is the technology); use of questions, and the expression of affect (particularly when communicating complex or sensitive information). Findings will inform co-design workshops with patients, clinicians, professional organisations (e.g. royal colleges) and policymakers (e.g. NHS Digital) with experience of remote consultations, and inform the co-production of information and guidance about communication strategies to support successful remote consultations. OUTPUTS: 1. Interim and final reports for NIHR; 2. Academic publications and conference presentations; 3. Briefing papers for policymakers and managers; and 4. Information and guidance for patients/carers and clinicians on how to get the most out of a remote consultation.

Lay abstract: There is a strong policy push for alternatives to face-to-face consultations in healthcare. Telephone consultations have been an option for years, and now remote consultations (using SkypeTM and similar technologies) are being piloted. The National Institute for Health Research and Wellcome Trust separately funded studies to collect data on remote consultations with doctors and nurses. We have a recently collected dataset of 37 remote consultations (with diabetes, cancer, and heart failure patients), with multi-channel video (i.e. recorded from the clinic and from the patient s home), research ethics committee approval, and informed consent from patient and clinician for research analysis. There have been concerns about whether remote consultations are as good as face-to-face in all aspects. Our initial analysis of the dataset suggests that such consultations have advantages (e.g. patients generally feel satisfied with the remote consultation &ndash; and many prefer consulting in the comfort of their own home with family around them; clinicians who use SkypeTM regularly are keen on this medium), but that remote consultations are different (e.g. compared to the equivalent face-to-face encounter the overall length is shorter, and there are more interruptions and repairs , i.e. the flow of conversation is less natural). These early findings suggest that a more detailed look at these recordings using techniques that allow a finer-grained analysis of verbal/non-verbal interaction would yield original and important findings about the communication strategies that make up a good remote consultation. This powerful technique has not been applied to remote consultations &ndash; partly because of the logistical difficulties of obtaining high-quality video and audio data at both ends of the consultation. Hence, this new dataset offers a unique opportunity to undertake more detailed analysis and, informed by that analysis, to produce guidance for patients and clinicians about how to use this kind of technology successfully in consultations.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;7.1 INDIVIDUAL CARE NEEDS
Health categories: METABOLIC AND ENDOCRINE;CANCER AND NEOPLASMS;CARDIOVASCULAR