# Who a digital-only pre-op pathway leaves behind

> In an RNSH audit of 1,532 patients who missed their digital pre-op questionnaire, 64% were over 65, 14.5% preferred a language other than English, and ophthalmology was the largest group at 385 patients. Incompletion rose with a specialty's average age. A web form asks a lot of these patients; a voice channel, fewer questions and a human fallback ask far less.

*Source: https://getpathways.ai/articles/who-digital-only-pre-op-leaves-behind*

The RNSH audit of 1,532 non-completing patients found clear patient-level
patterns:

- **64%** were over 65
- **14.5%** had a preferred language other than English
- **385 (25.1%)** were ophthalmology patients, the single largest specialty group

Across surgical specialties, incompletion rose roughly in line with the
specialty's average patient age. Ophthalmology sat at the top on both measures,
with incompletion close to a quarter and an average age in the low 70s. The
youngest specialties on the chart, ENT and gynaecology, sat at around 11%.

None of this is surprising. A 2024 systematic review in *JAMIA Open* (Senarath et
al.) catalogued the barriers older adults face with electronic patient-reported
measures. What the audit adds is scale and specificity: these are the patients a
busy tertiary hospital is actually losing.

## The ophthalmology problem

Ophthalmology patients face a double barrier. They are older on average, and
many are having surgery because they can't see well. A questionnaire on a phone
screen is hardest to complete for exactly the people booked in for eye surgery.

That makes ophthalmology the natural starting point for a different approach.
It is why the proposed PAINITE pathway at RNSH pilots its voicebot there first,
with a process evaluation before any wider rollout.

## "Digital literacy" puts the burden in the wrong place

It's common to describe these patients as having low digital literacy. That
framing makes completion the patient's job. A more useful question is whether
the hospital offers a channel this patient can use.

A web form asks a lot: an email or SMS link, a smartphone or computer, good
eyesight, confident English, and enough familiarity with medical terms to answer
without help. A phone conversation asks for far less.

## Design principles for an inclusive pre-op assessment

1. **Make voice a first-class channel.** A phone call works on a landline, needs
   no app or login, and lets the patient ask what a question means.
2. **Ask fewer questions.** Use what the hospital already holds, such as referral
   letters, GP summaries and medication lists, so patients only answer what is
   genuinely unknown.
3. **Speak the patient's language.** Multilingual conversation helps CALD
   patients, with a clear path to a human interpreter for anything clinically
   ambiguous.
4. **Let carers help, with consent.** Many older patients manage their health
   with a partner or adult child. The pathway should allow for that.
5. **Keep a human option.** Voice doesn't suit everyone. Patients with hearing
   loss or cognitive impairment still need a nurse on the phone or in clinic.
6. **Measure equity.** Report completion by age band, language and specialty, so
   gaps are visible before they become day-of-surgery surprises.

The authors also cite a 2024 systematic review and meta-analysis of
perioperative chatbots (Lin et al., *BMJ Health & Care Informatics*) among the
evidence for conversational approaches.

Digital-first pathways have real benefits: earlier risk identification, less
administrative load, more time for clinicians to focus on complex patients.
Digital-first can't mean digital-only. The patients who find web forms hardest
are often the ones who most need a careful pre-operative assessment.

*Source: Zhang D, Marks A, Doane M, et al. Barriers to current perioperative
digital platforms – how can innovation solve these issues? Poster, ASA CSC.
Specialty incompletion rates and average ages are read from the poster's Figure
2 and are approximate.*