NHS England » Online consultation tools

Digital tools are changing the way primary care is delivered. By providing practices with a range of features, digital tools enable them to develop new care pathways and workflows that can enhance the delivery of healthcare.

Decision-makers within practices need to understand how they can be used in real-world scenarios. This means understanding their capabilities, appreciating their differences, and choosing digital tools that will have the highest impact. Online consultation (OC) tools have a range of features that may benefit practices and patients alike. Choosing the right OC tool to meet the needs of the practice and local population is an important decision

NHS England has published a toolkit for practices on using online consultations in general practice, which you will find helpful.

There are also several other articles in this series covering digitally enabled triage, remote consulting, video consultation tools, and about procurement, regulation and governance of remote consultation tools.

Purpose

Online consultation tools allow patients to contact their practice without coming into the surgery or waiting on the telephone. They allow patients to provide the reason for their request and provide any clinical or admin-related information. They act as an entry point into the practice, a digital front door. In their simplest form, the tools allow online consultation requests to be directed to different services, appointment types, or consultations within the practice. Various tools are available, and they all operate in slightly different ways. The digital and online services requirements detail the minimum features OC tools must provide. As a minimum, they must allow the patient to:

make clinical or administrative requests
seek health advice

They use different methods to collect and analyse the information they receive from patients. They also have different feature sets which impact the experience for patients and clinicians.

OC tools use three basic methods when collecting clinical information from patients:

questionnaire-type – collects information on predefined forms based on the presenting complaint, often allowing free text entry
chatbot-type – collects information using a real-time chatbot that presents questions based on the answer to the previous question and the presenting complaint (free text entry is often limited)
online messaging-type – uses online messaging (OM) tools as the entry point for patients to initiate patient-led online consultations. They allow patients to free text their information directly to the practice through a two-way communication platform

Many of the tools use a combination of the three methods listed above, for example questionnaire-based tools that have direct secure messaging built into their package.

Understanding the different features of OC tools is important when choosing the right tool for your practice. As OC tools mature, they will be able to offer more advanced features. Table 1 is a brief overview of the feature sets available from current OC tools hosted on the national framework.

Table 1: Common OC tool features

Symptom Taking Style	Experience
Chatbot type	Presents questions to patients based on their presenting complaint and subsequent answers they provide. In most cases, patients cannot upload clinical photographs or provide free text entries. Patients are presented with drop-down options to pick from. This increases the amount of automation the tool can provide but may restrict the type of information patients can enter
Questionnaire type	Presents patients with predefined questions based on their presenting complaint. Patients can often provide additional free text information and clinical photographs. This may reduce the amount of automation but maximises the type of information patients can provide
Online messaging type	Patients can free text their queries and information directly to the practice. Admin or clinical staff can then interact dynamically via an Online Messaging (OM) tool through two-way messaging. Many of these systems also allow patients to reply with attachments such as photos or documents
Triage Style	Experience
Automated triage	Analyses patient-provided information and directs patients to the most appropriate care pathway or clinical service without additional human intervention
Practice-led triage	Patient responses are summarised, and a report is sent automatically to the practice for review and action. Allows practices and clinicians to have complete control of patient triage
General Features	Experience
In-built red flag /safeguarding	Automatically picks up red flag symptoms and alerts the patient to appropriate emergency or urgent care services
Time-based signposting	Ability to direct patients to self-help, pharmacy, and other local services within a clinically appropriate timeframe
Image/document upload	Patients can upload clinical images during the process. These images may be clinical images, clinical documents, prescription slips or other information the patient may want or have been asked to provide
Direct booking	The OC tool integrates with the electronic patient record and can offer patients an appropriate appointment slot to book directly
Online messaging	Feature for two-way patient messaging for questionnaire and chatbot-type tools
Built in video consultation/telephony	Incorporates video consultation and conferencing tools directly into the software
Demand control	Allows practices to choose when the OC tool is active for patients to use. Practices can use this to control the flow of information coming into the practice and match it to existing resources If demand becomes dangerously high practices may have the ability to temporarily turn off their OC tool.
Save to record	Automatically saves the summary into the record either as a document or as data directly into the electronic patient record
Automated SNOMED Coding	Automatically codes specific data points into the record using SNOMED CT. Practices should assess if this functionality is required, accurate and appropriate
Language translation	Built-in on-the-fly translation tools, becoming available in some Online messaging-type online consultation tools
Voice activation	Allows patients to respond using voice commands to the questions being asked – if present, it will normally feature in Chatbot-style OC tools.
NHS App integration	Enables patients to access the OC tool directly via the NHS App- Online consultations in the NHS App – NHS Digital
Processing dashboard	Platform to help practices manage the queue of OC requests and process them safely
Analytics dashboard	Business intelligence dashboards with data on the number of patients, types of presentations and outcomes. Useful for auditing and driving intelligence for quality or pathway improvement

Online consultation tools | History taking style

Amongst the features on offer, important considerations include:

the degree of free text entry
the automation capabilities of the tool, which should be considered in the following ways:
automated history-taking engines (chatbot style) that collect information without any free text entry
automated processing of this patient-provided information without human intervention to direct patients into a service or care pathway, g. automatically directing a musculoskeletal-related OC request by booking them in for a telephone call by a first-contact physiotherapy practitioner

Chatbot-type OC tools typically use an automated history-taking engine. Patients respond to predefined questions from predefined pick lists or options. In most cases, patients are unable to attach clinical images or documents. Conversely, questionnaire-type history-taking allows patients to describe their symptoms in their own words and often allows patients to attach clinical images and documents.

Figure 1: Automated history-taking engine vs free-text history taking

Tools limiting free text entry have increasing capabilities to automatically process the information provided by patients without the need for human intervention. These tools do not need to understand the contextual meaning of any free text entry by patients. The technology can then process the information provided against predefined rule sets. In some cases, it means they can automatically process information (without human intervention), and direct patients into a service or care pathway.

Tools that automatically process patient information requires a Data Protection Impact Assessment (DPIA). Many OC tools now allow a combination of automated history taking and free text entry.

There are advantages and disadvantages to the different methodologies and degrees of automation.

Advantages and pitfalls of online consultations tools

Benefits for patients

Implementing OC tools effectively can result in a variety of benefits for patients:

increased choice and flexibility when accessing care
new communication channels to contact the practice
ability to receive healthcare from their home or office
increasing flexibility of appointment times
improving access for issues patients find difficult to discuss in person or on the phone
improving access for patients with barriers imposed by poor mobility or distance
improving access for vulnerable groups or those with difficulties with social interaction
improving self-care for minor ailments and management of long-term conditions

Benefits for practices

Implementing OC tools effectively can also benefit practices:

increasing the amount of high-quality clinical information gathered before an appointment
ability to complete consultations via online messaging tools and increasing efficiencies
improving demand management for patient requests
opportunities for remote working or hybrid working
new channels to reach and contact patients for acute and chronic care delivery
freeing up telephone capacity for patients calling into the practice
more appropriate use of services within primary care
cost efficiencies for practices and primary care networks

Risks of poor planning

Poor planning carries several risks for both patients and practices:

digital exclusion for patient groups that find the use of technology difficult
poor demand management for practices
increased workload for practices and clinicians
barriers to access if practices become over-reliant on OC tools at the expense of traditional access channels
inappropriate triaging of patient requests using OC tools
patient uncertainty about when to use OC tools
patient uncertainty on how to use OC tools
a reduction in personalisation for some patients where tools do not allow them to express themselves freely
increasing online presence and risk of cyber crime

Choosing the right tools

Picking the right OC tool for your practice can be difficult. Remember to work closely with your commissioners, suppliers and local practices and learn from each other. A ‘one size fits all’ approach will not work. You need to match the tool to the needs and wants of the practice and your local population.

Remember you are unlikely to find an OC tool that can meet all your needs. Choose one that solves your high-priority short to medium-term challenges and can grow with your long-term strategic objectives.

Online messaging tools (as a feature of the online consultation tools or as a standalone product)

The core digital offer means patients must be able to communicate with the practice via electronic communications digitally. The diagram below shows some flows currently used for online messaging between patients and the surgery.

Figure 2: Online messaging flows in practice

Practices using NHSmail to reply to patients must remember to use the secure encryption facility when replying. To do this add the word [secure] in the subject line of a message – with the inclusion of the square brackets.

Most practices use a combination of the three methods detailed above, with many relying on OM tools either as part of their OC tool or as a standalone product to respond to patients.

OM tools have a variety of feature sets that can benefit patients and practices when compared to NHS mail or SMS. The new Digital first online consultation and video consultation framework (DFOVC) covers many OM tools currently in use, as many of these tools also offer OC and video consultation (VC) functionality.

Basic features

In their simplest form OM tools can be used to:

complete clinical requests from OC tools in the form of ‘written’ online consultations
send secure links for a video consultation via SMS (text messaging) or email
provide links to third-party information relevant to the management of the patient
send important information to the patient regarding results, or treatment plans
collect information in advance of an upcoming appointment

Mature features

OM tools with mature features offer a range of added benefits:

sending validated questionnaires for long-term disease management to fulfil Quality and outcomes framework (QOF) requirements
attaching and sending documents via secure links, such as fit notes or letters
scheduling batch messaging for the internal recall process and supporting the management of long-term conditions
scheduling reminder messages for patients
scheduling consecutive messages over different time periods
creating secure links for patients to attach clinical images to aid decision-making
configuration options to develop practice and user-specific templates when communicating with patients
dashboard with email inbox like facilities for users to track their sent, received, opened vs unopened messages
grouped inboxes for groups of clinicians managing a particular service, e.g. a dedicated inbox for respiratory nurses managing asthma control test questionnaire replies

Helpful features

The ability of each tool will differ. However, the features below can be helpful for practices when choosing an OM tool:

controlling and selecting when a patient can reply to a message
attaching documents directly from the patient record rather than having to download them onto the desktop station
previewing clinical images or documents sent by the patient before accepting them into the patient record
integration of completed questionnaires directly into the patient record
assignment of clinical codes such as SNOMED CT to messages, replies and questionnaires
warning system when a message has failed to send
inbox indicators that show the number of unread messages
allowing multiple attachments per message

Online messaging tools currently in use have many of the features listed above. The two-way messaging system means the initial contact can be clinician-initiated or patient-initiated.

The ability to allow a patient or clinician-initiated messaging can be very powerful. Further details on the practical use of OM tools when carrying out written consultations are covered in the Remote Consulting article.

Other helpful resources

NHS England, Dynamic Purchasing System (DPS) for digital social care record solutions
Digital Social Care, Assured Supplier List for social care
NHS Digital, Online consultations in the NHS App

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