Title: Care in Orthopaedics, burdeN of treatmeNt and the Effectiveness of Communication Technology: the CONNECT Project
Funder: Health Education England

Abstract: 1. Background a. Clinical backgroundWe have an ageing population frequently affected by life limiting conditions, often of musculoskeletal origin. Specialist orthopaedic care is required but accessing such care is challenging. The NHS five year forward view is based around new models of care with e-health technology identified as one possible innovation to support access to care. Despite positive outcomes from previously conducted telehealth research uptake in clinical practice remains low.Patients attend the Royal National Orthopaedic Hospital (RNOH) for physiotherapy from all over the country. Patients often find the travel challenging and this research aims to design, implement and evaluate a technology supported consultation to enable access to care without the need for repeated face to face attendance. Our previous research (Gilbert et al 2016) found that SKYPE consultations were not acceptable to all patients and the acceptability of this consultation format is multi factorial and warrants further investigation. b. Theoretical background The proposed research utilises three theoretical models; Normalisation Process Theory (NPT) (May 2013) to explain the work of using e-health technology, Burden of Treatment Theory (BoT) (May et al 2014) to explore the work RNOH patients are required to do to participate in tertiary orthopaedic healthcare and Minimally Disruptive Medicine (MDM) (May et al 2009). A minimally disruptive' physiotherapy consultation is one that: - has minimum negative impact on the patient's life- offers reduced workload for the patient- healthcare professionals and care are accessible to the patient The proposed research involves the novel integration of sociological and economic methodology to explore this issue. 2. AimTo design, implement and evaluate a minimally disruptive' consultation format in an orthopaedic setting. 3. Plan of Investigation Phase 1 (months 1-6) The purpose of phase 1 is to review literature reporting the use of e-health technology in an orthopaedic setting using NPT with a particular focus on: a) What technologies are used in orthopaedic practice to support access to care?b) What is the work that patients and clinicians are required to do to use these technologies? Phase 2 (months 6-12)A taxonomy of work and tasks for both patients and clinicians to engage with these technologies will have been developed in phase 1 and will be used to determine how these tasks affect the patient's treatment burden. This phase will also explore how the introduction of e-health technology affects negative impact for patients. Phase 3 (months 13-21)A Discrete Choice Experiment (DCE) will be designed and conducted to ascertain the most important factors determining patient acceptability on the introduction of e-health technology. Phase 4 (months 2130) [Modified Clinical Practice]Upon completion of the DCE patient preferences surrounding the amount and type of work required to engage in the consultation will have been identified. A minimally disruptive consultation format will then be designed, implemented and evaluated, using semi structured interviews. An important focus will be the determination of whether the modified clinical practice makes it easier for patients to participate in their healthcare. 5. Benefit to patients and the NHSPrevious studies of the introduction of e-health technologies have utilised top down models rarely leading to routine uptake. To our knowledge, no previous work has explored the role of patient preference in technology normalisation processes, and it is postulated that the knowledge of such patient preferences is more likely to lead to successful e-health implementation. This project will focus specifically on orthopaedic physiotherapy appointments but it will have much wider implications for the introduction of e-health technology to other spheres of the NHS. There is the potential to both provide a better patient service and to effect cost savings.

Lay abstract: Introduction People are living longer and the need for health care is rising. One new way of providing health care is with the use of technology to save people from travelling to hospitals, especially specialist services where patients travel considerable distances. Research has been carried out, along these lines, to find out how technology can help patients get the care they need. This research showed that even though technology was found to be useful, it has not yet been incorporated much in clinical practice. Patients attend the Royal National Orthopaedic Hospital (RNOH), a national specialist centre, for physiotherapy from all over the country. Patients often find the travel to get to the RNOH challenging. We have already looked at how technology can be used to help patients see their physiotherapist and occupational therapist at hospital regarding their shoulder problems. Some patients chose to take up the option of using the video call and others did not want to. Patients who chose to use video call found that this reduced the need to travel and its use greatly improved their experience. It is important to now look at what patients like and do not like about using technology and design a new way for patients to use this technology to support communication. This will support them to get the help they need for their health problems. This research aims to design, implement and evaluate a technology supported consultation to enable access to care without the need for repeated face to face attendance. I will do this in four stages: Phase 1Review of previously published research on the topicI will search for previously published research looking at how technology helps people with bone and joint problems get the healthcare they need. I will then look at the work patients and staff need to do to use this technology. Phase 2Interviews with patients and hospital staffI will speak to patients and staff in structured interviews find their view on how technology could be used to achieve the best health outcomes and whether or not this technology would make it easier for patients. Phase 3Deliver a survey of patientsI will ask patients to choose, from a list of options, their preferred consultation format for getting the care they need from the physiotherapist. Some options will be using technology to support the consultation. Patients will be asked to choose which options they prefer as if they had that option to choose from for their own healthcare. Phase 4Design a new way of working using digital technologyUsing the information gathered in phase three I will design a new way for patients to access the care they need. I will then ask patients and hospital staff to evaluate their experience of using this technology.The results of this work will be presented in research journals and at research meetings, the CONNECT Project website and using social media such as twitter and blogs. I have set up a patient and public involvement group and this group will be actively involved in helping drive the research forwards at each stage of the research. The steering group consists of 10 members (consisting of RNOH patients and members of the public), a technical author to support with plain English summaries and two steering group co-chairs consisting of a member of the public and an RNOH Physiotherapist. To our knowledge, no previous work has explored the role of patient choice and its role in the uptake of technology. It is thought that knowledge of patient preference will help clinicians, researchers and policy makers to better understand how lead the introduction of technology supported appointments. This project will focus specifically on orthopaedic physiotherapy appointments but it will assist in supporting the take up of technology in other areas of the NHS to both provide a better patient service and reduce costs to the NHS and patients.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MUSCULOSKELETAL