Are virtual clinics an applicable model for service improvement in cardiac surgery?

A virtual clinic is a method of service delivery by establishing communications and working relationships among patients, doctors and insurance companies to facilitate the remote diagnosis and treatment of patients [1]. The communication can be synchronous where a doctor interacts with a patient at real time or asynchronous when communication done through messages, emails or a discussion board. In the USA a patent exists of virtual clinic for medical practice, which may be used as guideline for specialists who are interested in adopting the model in their practice [1]. Virtual clinics exist for other medical and surgical specialties and their use is expanding [2, 3], but for cardiac surgery no evidence still exists in practice. Among the medical entities for which patients are seen in a virtual clinic environment are inflammatory bowel disease [4], diabetes [5], lung [6] and kidney disease [3]. For surgical specialties the majority of the evidence exists on orthopaedic surgery [2, 7, 8], especially in fracture clinics for which the implementation has been quite successful. Processes for a virtual clinic which are applicable to one specialty might not be transferrable to a different one. The posting of instructions before the virtual clinic appointment [4], the use of a questionnaires to screen patients who need an actual outpatient appointment [2] or for progress check [8] and the ordering of blood tests and X-rays and other investigations [4] in primary care facilities are among the processes which would apply as well to a cardiac surgery virtual clinic. Even the use of a discussion board [5] might be useful; it would allow patients to exchange experiences and reduce preoperative anxiety. For orthopaedic surgery, PROM 2.0 has been used widely; a web-based platform which collects patient reported outcome measures (PROMs) [8]. PROMs are short sets of questions developed from clinical research, which measure patient symptoms, such as joint function and pain and are especially useful for checking progress and at identifying the patients who will eventually need an actual outpatient clinic. These measures can also be utilized to compare different patient’s progress or the postoperative to preoperative state of an individual patient. In cardiac surgery PROMs would be very useful but first specific ones for different type of operations (i.e. aortic valve replacement, mitral valve repair, coronary artery bypass grafting) do not exist per se and secondly their sensitivity will need to be evaluated. Taking as an example a postoperative follow-up appointment in an outpatient clinic after a cardiac procedure, which commonly happens 6 weeks post-discharge, a history taking and physical examination is performed. The history includes the collection of data regarding the mobility of the patient and any symptoms (i.e. chest pain or shortness of breath) present. The physical examination involves measurement of the vitals, weighing the patient, checking the stability of the sternum, examination of all surgical wounds and auscultation of the heart and the lungs. A check of the medication is also performed to decide which medications will need to be continued. Finally, any tests required will be ordered and any further questions that the patient might have commonly regarding his work or his lifestyle are answered. In contrast, a virtual clinic visit will start with a specific to the operation questionnaire that the patient will need to complete. The surgeon will then ask the patient to weigh himself, record his temperature, his pulse and his blood pressure. The surgeon is able to visualize the patient and get additional information such as whether he is in pain or short of breath and check from a distance his surgical wounds. Following this and as part of the physical examination the surgeon will ask the patient to place an electronic stethoscope over different points of his chest for heart/lung auscultation purposes. Instructions can be available online or sent my mail. In the event that a chest X-ray, ECG or blood test is needed these can be ordered electronically and then the patient can be referred to a diagnostic centre to have these tests done; the results will be sent to the surgeon electronically for review. For any medication prescriptions required these can be sent to the pharmacy directly for the patient to pick them up. If indicated the patient can always come to the hospital for a more detailed examination. An advantage of the virtual clinic is that the surgeon does not need to maintain specific visiting hours and can even evaluate patients at home any time. Furthermore, the patients do not have to travel far away to come to the hospital and lose work hours; a virtual appointment can be arranged at a time when both parties will be available. Thus, the process by limiting costs and waiting times, and avoiding unnecessary visits and ineffective use of health resources may be more cost-effective. Virtual clinic provides a platform for collaboration of different specialties and resources in a timely way. Even more importantly the resources are available all the time and the patients have access to them when required. For the surgeon the collection of validated measures of patient outcome and evaluation can provide an insight to his service. On the other hand, a major disadvantage is that important information on the physical examination (related to the sense of touch) such as having a feeling of the stability of the sternum or hands on examination of an infected wound will not be available. Thus the safety and efficiency of medical care may be compromised and cases of wrong diagnosis from lack of information may be anticipated. Nevertheless, when any concerns are present from the view of a wound or from related symptoms complained by the patient a face-to-face meeting at the hospital can always be arranged. In the last years, with the advance of technology medicine is becoming more and more impersonal and distanced from the patient. Virtual clinics are heading as well towards this direction. A physical contact can never replace a virtual one especially in cases where a patient might be in need of ‘a hand to lean on’, which is quite common before or following an operation. Continuing on the same context, older patients might not have access to the technology or be able to follow successfully the instructions for a self-examination. An additional issue of critical importance is the implementation of a strict information governance protocol that would rectify the security of the communications, data collection and safe access to it by both parties, something that will need to be addressed at a design level. No current evidence exists of how well a virtual clinic would run in cardiac surgery and at what stage of care it would be more successful. Studies are needed, as have been already done in other specialties, to compare its efficacy and cost-effectiveness to a traditional outpatient appointment. For this purpose any metrics created and used for assessment will be required first to be validated before use. Satisfaction surveys have been employed in other specialties as well as calculation of the actual cost gain per patient. Quality-adjusted life years (QALYs) have been widely utilized as a measure of improvement in quality of life associated with an intervention or treatment. In the UK NICE accepts as cost effective intervention the one with an incremental cost-effectiveness ratio of less than £20,000 per QALY [9]. A virtual clinic will have to measure up to this standard of cost-effectiveness before its widespread implementation. A virtual clinic seems to be feasible in cardiac surgery at least for particular patient groups. Important advantages are present, which need to be weighted against significant disadvantages. Definitely, it is an innovative business model of care which is left to be tested in practice to establish its applicability and efficiency in the future. Conflict of interest: none declared.