NHS England has published a summary of a study commissioned to explore clinician views on the use of digital technology in the autism assessment pathway, with the results noting an overall positive attitude from clinicians along with several challenges, including a need for training, difficulties in assessing social communication via video, and worries around digital exclusion.
Clinicians commented on positive factors around the practicalities of telehealth, particularly around flexibility and efficiency. However, logistical barriers around IT and engagement were also noted, along with the risk of digital poverty contributing to inequalities.
Feedback noted limited standardisation across telehealth autism diagnostic assessment services, with different numbers of clinicians involved in assessments; different types of behavioural observation assessments used; different numbers of appointments offered in total; and variation in overall assessment duration. A “potential for lack of inter-rater reliability in diagnostic outcomes” was therefore highlighted.
On validity and reliability, many of the clinicians said that their opinion on telehealth validity improved over the course of the pandemic, though some commented that reliability of telehealth assessments can be affected by factors such as the patient’s age, any speech or language difficulties, learning difficulties, or an intellectual disability.
With regards to assessment tools, the study noted that many services have developed an observation schedule and assessment for telehealth use, but as they had not been empirically tested, “their psychometric properties were unknown” and “professionals were more cautious about interpreting their results”.
Feedback from the clinicians also highlighted that virtual assessments can create unrelated judgements; for example, an internet connectivity issue could mask a patient missing a social cue. However, they also commented that seeing the patient’s home environment can support in observing preferences and difficulties as well as giving insight into relationships between patients and families, acknowledging that the familiar environment could also impact on the patient’s observed behaviours.
In terms of diagnostic conclusions, the study surfaced views that telehealth assessments “may introduce greater uncertainty between professionals when compared with in-person assessment”, with some participants commenting that they would not confirm a diagnosis for someone they had not met in person. In addition, some clinicians believed that giving a diagnosis over the internet could be seen to be insensitive.
On clinical considerations, some clinicians raised the view that telehealth assessments during the pandemic led to patients with straightforward presentations being seen in a timely manner whilst those with more complex presentations had to wait longer. They also pointed out that should safeguarding issues arise during a remote assessment, it would potentially be more difficult to respond urgently using virtual means.
Regarding future ways of working, most clinicians were “happy to implement a hybrid model” following the pandemic, as long as assessment quality was not compromised. Some possible innovations were suggested, including allowing videos to be shared of patient behaviour in everyday scenarios; eye-tracking or neuropsychological tasks; or use of multiple cameras to observe behaviour from different angles.
Training was raised as a specific point, with none of the clinicians participating in the study receiving any training on conducting electronic assessments prior to the pandemic.
The study summary can be found in full here.
The NHS England board papers from the meeting earlier this month share an update on the learning disability and autism programme update, including a number of actions undertaken to address health inequalities in this space. HTN covered the digital content of the board papers here.