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Red flag warnings are essential to any online consultation platform

Irene Reguilon  | 26th February 2021
drop in urgent eConsults

You wouldn’t drive a car without seatbelts or an airbag. These are safety features that you hope won’t be necessary, but they are there in case something goes wrong. In-built red flag warnings, safety nets, structured questions and clinically designed questions do the same thing as an airbag for online consultations. They are there to ensure that no patient comes to harm.

At eConsult we take clinical safety extremely seriously.

Built into the eConsult algorithms are various clinical safety nets which have allowed us to safely support over 10 million patients to complete an online consultation with their GP surgery. We don’t hope critically ill patients use eConsult, but we know it will and does happen. Our safety nets are there for those moments. 

Urgent warnings – Think of them as a safety net

One of our clinical safety nets is our urgent warnings. These are triggered by our algorithms when patients answer questions in a way that leads us to believe they should seek more urgent assistance than an online consultation can offer.

It is a constant balance to ensure our urgent warnings are identifying all the patients who need more urgent assistance while making sure we are not over-flagging patients who could be treated effectively by their GP.

When a patient submits any kind of online consultation it is sent to the practice to be reviewed. Depending on how the practice operates, a member of staff at the practice will review the submission – but that could be anywhere from a few hours after the submission to ‘by the end of the next working day’.

Without any urgent warnings or red flags built-in, a patient who is experiencing serious symptoms could be left waiting until their GP surgery responds. This is particularly relevant when the surgery is closed. Consequently, there is the potential for patient harm if this leads to a delay in diagnosis and the provision of prompt treatment. 

Example of our urgent warning screen.

There is a balance between being too risk-averse and not including urgent warnings. Our Clinical Governance and Development teams continuously review our eConsult platform to respond to feedback, improve our content and maintain clinical safety. 

After analysing 5,000 urgent warnings on an anonymised basis, we discovered that musculoskeletal (MSK) questionnaires made up around 19% of these urgent warnings.  Further analysis found that 31% of these MSK urgent warnings were related to a question about the patient’s perception of their pain.

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What are pain scores?

We ask patients to rate the pain they are in as a score between 1 and 10. When these questionnaires were designed by our clinicians and reviewed by our Clinical Governance Team, the original view was that any pain score above a 7 should not be waiting for a GP to contact them and the patient should be told to contact 111 to seek more immediate advice. 

We received feedback from our GP users that patients have a tendency to overestimate the pain they are in, which is backed up by research. This means that potentially we were being overcautious by redirecting patients who indicate a pain score above 7 out of 10 in our MSK questionnaires.

Example of a 1 to 10 scale pain score question

Our Clinical team got to work reviewing our pain scores and associated question sets. Out of the 31% of urgent warnings related to pain scores, 10% were deemed high-risk, such as those linked to chest or abdominal pain. Around 21% were deemed a lower risk and therefore permitted to be submitted as an online consultation with flagging on the eConsult report, where applicable. 

As a result of this, we have updated ten of our MSK questionnaires to stop them from triggering an urgent warning if the patient indicates a 7 or higher pain score. We have also added a functional pain score to these templates so that the reviewing clinician can get a better idea of the impact that this pain is having on the patient.

Pain is incredibly subjective – one patient’s 1 out of 10 pain score may be another patient’s 7 out of 10. We have taken our learnings from our urgent and emergency care product, eTriage, to create a more functional pain score which we know gives a more accurate measure of the patient’s pain.

Our new functional pain score question

What impact has this change had?

The data so far have been very promising, and we have seen a substantial reduction in ‘urgent’ eConsults across the MSK questionnaires we’ve made adjustments to, as you can see from the graphs below (changes made around the 25th January 2021). Across these questionnaires, on average 9% are now marked as urgent, instead of the 17% from before we made these changes.

Overall decrease in urgent eConsults submissions following the change in pain scoring.

As examples across specific questionnaires, the percentage of urgent Foot Pain eConsults dropped from around 16% to around 9%, with similar reductions seen in Back Pain and even greater reductions seen in Shoulder Pain (from around 20% to around 5% after implementing the functional pain scores). We are continuing to monitor this to see if further improvements can be made. 

What next?

Improving the pain scoring across the MSK questionnaires is just the start. We knew that these questionnaires in particular were causing some patients to be directed to more urgent care unnecessarily. We can now start to look at other areas to test and potentially update. Watch this space!

eConsult is fundamentally built on ensuring patient safety. We include multiple levels of clinical safety net so that no patient comes to harm while using eConsult. As more patients continue to use online consultation platforms, this level of safety is essential for any provider. As a company, we are working hard to improve the user experience, while maintaining patient safety. We constantly monitor and tweak our content to ensure we get the right balance.


Written by:

Dr Aravinth Balachandran, MRCGP, BSs | Chief Medical Officer.

Aravinth qualified from the University College London Medical School in 2002 and has been working as a qualified GP since 2008. A Partner at his practice, Aravinth currently sees patients at Oaklands Health Centre in Hythe, Kent.