This feasibility study explored some novel facets of the consent-process, with participating patients accepting a digital interface as an adjunct to their in person clinical consultation. Patients found the information easy to read and convenient, and liked the multimedia approach (Table
5).
Participant recruitment
Although initial recruitment was poor, this was primarily due to the initial study set-up which required patient participants to type the study site URL into a web-browser to obtain access to the patient-facing digital platform. This was primarily due to stringent local information governance parameters, which were amended following further patient and public involvement, and further ethics committee approvals. Subsequent recruitment processes allowed patients to receive a hot link by either email or SMS with direct links to the study site and resultant improvements in participant recruitment (Supplementary Fig. 2). This emphasises the importance for digital platforms to be intuitive and easy to use.
A systematic review of digital tools for informed consent assessed understanding, satisfaction, anxiety and participation [
8]. Digital technologies did not affect any outcome negatively and overall they had a positive effect, particularly in informed consent for clinical procedures when compared with informed consent for participation in research [
8]. The authors also found that for clinical procedures, there was no benefit in the clinician being present during the digital sharing of information [
8].
Understanding of the consent information
The median time accessing the consent information was 17 min. This was similar to that found in a digital consent system utilised in orthopaedic surgery [
9] and demonstrates good patient engagement. Patients demonstrated their understanding of the information required for informed consent by self-assessment, through answering 10 multiple-choice questions on gallstone disease and the available treatment (Table
4). Paragraph 27 of the new GMC guidance on consent states that patients need relevant information to be shared in a way they can understand and retain, so they can use it to make a decision [
3]. Providing information in multimedia formats with interaction and teach-back techniques, as used in our digital platform, is the most effective way to help patients to retain information [
10].
Digital information delivered on our platform allowed the patient to choose the place and time to engage with the information prior to attending clinic with no time pressure and no risk of coercion from the clinician, in accordance with the GMC guidance [
3]. Coercion or pressure from the clinician was one of the findings of the Patterson inquiry in the UK, which recommended a two stage process of informed consent [
11]. Furthermore, our digital platform gives complete traceability to the hospital in terms of what information was shared, the time the patient spent engaging, and questions answered, giving a measure of understanding. This ability to capture metrics associated with the consent procedure is a recognised benefit of digital consent [
12] and could be important medicolegally [
13,
14].
It is best to consider informed consent as two separate stages—the sharing of information and the clinical interaction where clinician and patient have a meaningful conversation leading to shared decision-making. Our study suggests sharing of information is best performed digitally and does not require the presence of a clinician, saving clinician time and, potentially, an unnecessary hospital visit for the patient. The second-stage does require both patient and clinician, and works best if the patient is pre-informed. The clinician confirms the procedure is recommended, confirms patient capacity to provide informed consent, and focuses on what matters to the informed patient, by answering relevant questions. This is also an opportunity for the clinician to adjust risks from the standard for that patient. This two-stage process with a pause to reflect [
11] will become standard practice in the NHS [
2]. The process is completed with a signed consent form (digital or paper), assuming the patient voluntarily decides to proceed. Digital consent solutions which take the patient and clinician through this process have been developed and are entering clinical practice [
15].
These digitally supported systems allow the consultation to focus on “what matters to the patient” in the form of questions they wanted to ask the clinician. Since the Montgomery Ruling [
4] the aspect of discussing “what matters to the patient” is a medicolegal imperative and is one of the 7 principles of informed consent defined by the GMC [
3].
Patient health questionnaire
Preoperative assessment is an important next step in the elective surgery pathway ensuring the patient is fit enough for the proposed surgery and that optimisation of their health can take place prior to surgery [
16]. Digital preoperative questionnaires have been developed to screen patients so that only those who need to attend the preoperative assessment unit do so, with a view to saving time and resources [
17]. In our study we compared patient self-reporting of health status with that performed by a healthcare professional, finding no statistical differences in most health-related questions. This raises the possibility of an automated patient-driven process as an adjunct or an alternative to routine processes. Further adequately powered studies are, however, required to determine if digital preoperative questionnaires can safely replace face-to-face preoperative assessment in a proportion of patients.
Strengths and weaknesses
This feasibility study has provided strong evidence to support the process of informed consent, from measuring patient engagement, to providing a method for patients to self-assess knowledge acquired. It also demonstrates that patients can give a reasonably accurate self-report of their medical conditions. However, the relatively low number of registrations compared with those invited (39%) in our pre-COVID-19 study was disappointing. Initial invitation was by letter requiring users to type in a long URL into their digital device. There was a significant improvement in uptake when either an SMS message or email with a web-link was also sent (Supplementary Fig. 2). As might be expected, we found that the mean age of participants was lower than non-participants as getting older patients to engage in technology is sometimes a challenge.
One of the few advantages of COVID-19 has been the improved familiarity of the public with healthcare digital platforms [
18]. Therefore, it is likely that similar platforms would gain a higher usage particularly as the “digital first” message gets across and as the government take steps to improve digital inclusion [
19]. Furthermore, engagement should improve when digital platforms become an integral part of elective care of the patient using established lines of communication e.g. NHS App [
2] rather than an invitation to participate in research.
User experience (UX) is key to the success of any digital platform and is a whole industry in itself [
20]. Feedback from our users (Table
5) demonstrated several valuable lessons. Firstly, the security checks for logging in and repeated lock outs were very frustrating and deterred them from using the platform. They also found the platform was difficult to use on mobile devices. Furthermore, users complained that there were too many questions with too much repetition. The use of standardised, validated ePROMs questionnaires involved 36 generic questions and 6 specific questions. There were also 10 consent understanding questions and 17 preoperative health questions making a total of 69 questions for the initial assessment. This “question fatigue” was manifest in a high dropout rate over time [
5]. With respect to informed consent metrics, true understanding can only be captured by correct answers to questions. However, indirect metrics can be captured by the system without the user having to answer questions, such as the time spent engaging with the information, the clicks onto additional information, or the playing of animations. This will improve the user experience whilst still collecting valuable metrics which demonstrate that the informed consent process has taken place.
We have listened to the user feedback from this pilot project and have developed a next-generation digital platform for sharing high quality, plain English crystal marked patient information for most medical and surgical procedures ensuring good user experience, which works on all types of devices. Additionally, gathering background metrics to demonstrate that quality information sharing has taken place to support informed consent.
Unfortunately, clinician feedback on the presence of a clinical report prior to clinic consultation and its impact on the consultation was not measured. However, patient user feedback on the digital platform did include positive comments about the quality and simplicity of the information provided, and the benefit of multimedia adjuncts such as videos and animations. The information was felt to be “easy to read and navigate”, and made users feel that they were a part of the shared decision-making process. One user stated that “The process makes me feel responsible for making a good decision about my own healthcare”.
Future work
As digital consent solutions are implemented in healthcare, we will be measuring the impact of these healthcare technologies in terms of user experience of both clinicians and patients, user satisfaction with the informed consent process, and ultimately the impact on reducing litigation for “failure to inform”.