The Challenges of Remote Care in a Stressed System
The rapid expansion of remote triage and remote consultations in primary care during the COVID-19 pandemic occurred against a backdrop of unprecedented system stress. Many organizations faced insufficient telephone lines or call handlers, leaving patients struggling to access services. Most remote encounters were conducted by telephone, which can limit clinicians’ ability to gather vital information and assess patients effectively.
Safety incidents – defined as “any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare” – are extremely rare in primary care overall. However, the widespread shift to remote modalities raised concerns about patient safety, as a wider range of patients and conditions were now being managed remotely.
Our multimethod qualitative study aimed to uncover the reasons why safety incidents occasionally occur in remote primary care encounters, as well as the creative ways in which frontline staff work to prevent them. We analyzed 95 real-world safety incidents involving remote interactions, and conducted a longitudinal ethnographic study of 12 general practices across the UK.
Organizational Challenges and the Impact on Safety
The context in which remote encounters were taking place was highly challenging. General practices were facing resource constraints, understaffing, and high demand. Triage and care pathways had become increasingly complex, often involving multiple staff members across different locations and shifts.
In this strained environment, safety often depended on individual staff members taking initiative, speaking up, or personalizing solutions. For example, we observed receptionists adding “high-risk” patients to urgent call-back lists, even when their symptoms did not initially seem severe. Clinicians would sometimes override rigid triage rules to bring in patients for in-person assessment when their gut instinct told them something was amiss.
These creative, safety-conscious actions by frontline staff helped to mitigate the risks inherent in the system. However, the overall lack of resilience meant that even minor disruptions, such as a distracted staff member or a technical glitch, could sometimes lead to serious consequences.
Limitations of Remote Consultations
Remote consultations, whether by telephone or video, rely heavily on the patient’s history and self-reported symptoms. Without the ability to perform a physical examination or observe the patient’s overall demeanor, clinicians can miss crucial diagnostic cues.
Many of the safety incidents we analyzed involved missed, inaccurate, or delayed diagnoses – for example, failing to recognize symptoms of a cardiac emergency, an acute abdomen, or a deteriorating chronic condition. Patients with complex pre-existing conditions, vague or generalized symptoms, or difficulty communicating were particularly vulnerable.
Safety netting – the process of ensuring appropriate follow-up and monitoring – was also often inadequate in remote encounters. Clinicians may have felt reassured by the patient’s own description of their symptoms, only to later realize the severity had been underestimated.
The Burden on Patients and Carers
The shift to remote care has also placed additional burdens on patients and their caregivers. Navigating the often complex access routes to remote services can be challenging, especially for the elderly, those with limited digital literacy, or those with language barriers.
Patients are increasingly expected to take on tasks like self-monitoring, interpreting their own symptoms, and conveying this information effectively during a remote consultation. Those with cognitive impairments, physical disabilities, or limited health literacy may struggle with these added responsibilities.
In some cases, we found that patients resorted to “gaming the system” by adapting their story to obtain the in-person appointment they felt they needed. This could lead to inaccurate information in the patient’s record, further complicating care.
Building a Culture of Safety
Despite the inherent risks of remote care, safety incidents resulting in death or serious harm remain extremely rare in primary care. This is a testament to the creative ways in which frontline staff work to keep patients safe.
We observed numerous examples of staff using both formal tools (such as “high-risk” patient lists) and informal measures (like unscheduled home visits) to compensate for the limitations of remote interactions. Clinicians would sometimes override rigid protocols when their clinical judgment told them something was amiss, or ask support staff to perform additional “check-in” calls.
These subtle and adaptive safety practices, often developed through experience and shared within teams, represent an important part of the overall safety culture in general practice. As remote modalities become further mainstreamed, it will be crucial to recognize and support these frontline efforts, while also providing targeted training to help staff navigate the unique challenges of remote care.
Recommendations for Improving Patient Safety
Based on our findings, we suggest the following strategies to enhance patient safety in remote primary care encounters:
For Patients and Caregivers:
– Advocate for in-person appointments if you have difficulty communicating or describing your symptoms remotely
– Ensure you have access to necessary technologies (e.g., smartphone, internet) and the skills to use them
– Be prepared to provide detailed information about your medical history and current symptoms
– Speak up if you feel your concerns are not being adequately addressed
For Practices and Clinicians:
– Provide targeted training for staff on the unique challenges of remote consultations, including rapport-building, information-gathering, and safety netting
– Develop flexible protocols that allow clinicians to override rigid triage rules when their clinical judgment deems it necessary
– Foster a culture where support staff feel empowered to escalate concerns and advocate for patients
– Invest in technologies and workflows that enhance remote clinical assessment (e.g., high-quality video, remote monitoring devices)
For Policymakers and System Leaders:
– Ensure primary care organizations have sufficient resources to meet demand and maintain safe staffing levels
– Streamline and simplify remote access pathways to reduce complexity and burden on patients
– Develop national guidance on best practices for remote care delivery, with a focus on patient safety
– Support research and evaluation to continuously improve the safety of remote primary care encounters
By addressing the systemic, organizational, and individual factors that contribute to safety incidents, we can help ensure that the benefits of remote care are realized while minimizing the risks. Ultimately, the creativity and commitment of frontline staff will be essential in building a culture of safety that keeps patients at the heart of primary care, whether in-person or remotely.
