What are some best practices for transitioning to virtual (telemedicine) services?

Posted on April 13, 2020 by Jennifer Mullowney updated by Kate Jackson

Summary

Physicians have been encouraged to connect with patients virtually, when possible, to minimize risk of exposure to COVID-19. Current guidelines outline hardware and software requirements for providing virtual care, as well as suggestions for engaging with patients safely and effectively using telemedicine.

I.   How Can Virtual Care assist physicians during COVID-19?

  • Virtual Care is a powerful tool in Canada’s national efforts to contain the spread of COVID-19 by allowing physicians and patients to connect safely at a distance, minimizing the risk of community infection.(1)
  • The technology to provide virtual consultation is  currently widely available on  virtually any mobile device that allows a patient to connect to a doctor. (2)
  • Virtual Care can assist physicians screen patients, including gathering relevant travel and exposure history and furthermore assess symptoms, severity, treatment options, or redirect  patients to an in-office visit, screening/test facility, acute care facility ((1)
  • Virtual Care can monitor progress and check in on patients in isolation
  • Virtual Care can connect with regular or acute patients (that may not require a physical exam) patients to avoid unnecessary trips to the office. (3)
  • Virtual Care can communicate with multiple at once, including family members and/or caregivers (2)
  • Virtual Care can connect with colleagues to share information and seek additional clinical input(1)

II.   CHOOSING SOFTWARE:

  • There are various secure and non secure technology platforms offering virtual consultations.
  • Before selecting a solution consider what kind of virtual consultations you would like to offer patients, notably whether secure messaging or integration with electronic medical records is required and observing patient preference. (3)
  • The technology that you use should ensure privacy and confidentiality of patient information. You should always practice virtual consultations using a specific practice account to avoid patient identity being exposed to any other organization.(4)
  • There are various secure and non-secure technology platforms that physicians can employ to connect with patients including:
    • Think Research VirtualCare
    • iTelemed
    • Cloud DX (powered by Zoom)
    • Doxy.me
    • InputHealth Collaborative Care Record (secure offering online booking, intake/follow up assessment, integrated charting)
    • Insig (integrated with EMR Advantage)
    • Livecare ( designed by Canadian physicians, offering a free 30-day trial)
    • Medeo (integrated with Accuro EMR, available as a mobile app)
    • MediSEEN
    • Novari eVisit (web and mobile apps on Android &iOS)
    • OnCall Health (secure video conferencing, secure instant messaging)
    • TELUS EMR (free of charge for 4 months from activation)
    • VirtualClinic+ (work with any EMR, integrates to OSCAR) (3)

III.   Technologies not traditionally used or recommended in Health care include:

  • Skype and Teams (Microsoft)
  • Facetime
  • Zoom.us
  • Google Hangouts
  • WhatsApp(3)

IV.   HARDWARE COMPONENTS

  • Ensure you have adequate screen space to accommodate the patient video image
  • Invest in a good high definition camera (S100) and position it ideally on a desktop screen to that its above the image of the patient (5)
  • Invest in high good quality speakers, earphones or headphones. Earphones/headphones add an additional layer of privacy.(5)
  • If you cannot access forms through electronic medical records, you will need secure electronic storage for forms and copies that you complete and sign. Use a USB key that automatically encrypts the data it stores (about $50.00) and secure it with a strong password of more than 12 characters. (5)

V.   MANAGING HIGH QUALITY CONSULTATIONS

BEFORE

  • Confirm that virtual care is clinically appropriate for this patients
  • Issue in advance to the patient a statement that initiate the Virtual Patient Encounter  by reviewing the inherent benefits and  risks (privacy and security breaches) that may occur as result of using Virtual Care
  • Obtain consent (written if possible) (3)
  • Plan to use a private, well lit neutral room/ office and ask the patient to do the same
  • Plan on wearing clinical dress/ white coat as research show that patients of all ages prefer doctors to wear white coats as it reinforces that you are a health professional.(5)
  • Arrange an appointment time through existing office or remote platform technology
  • Know how you will access the patient’s notes before/after the consultation (4)
  • Have your equipment in place and tested in advance
  • Have a Plan B in place with your patient such as rescheduling, using the phone in case technology isn’t working properly (4)
  • Issue an appointment reminder ( call, SMS) to the patient where appropriate
  • Eliminate all distractions from your computer and surrounding, turn off all visible and audible computer notification, which create noticeable distraction.(5)

 

STARTING THE CONSULTATION

  • Initiate the consultation by saying something  eg “Can you hear/see me?”
  • Confirm the identity of the patient through sighting government issued identification and anyone else on the call with you or with the patient (5)
  • Confirm that the patient is in a province/territory where you hold a licence and billing number, physicians must be licenced where the patient is located so as the patient which city and province/territory they are in and record that in the chart(5)
  • Ask whether the patient is in an appropriate private location, record response. (2)
  • Take and record verbal consent in the chart for the virtual consultation (4)
  • Explain what can or cannot be done on a virtual consultation.(4)
  • Revert to plan B if there are major disruptions

 

DURING THE CONSULTATION

  • Provide instruction on how to capture visual information – come close to the camera or take and send a photo.(4)
  • Let the patient know when you are taking notes or reading something -silence is OK(4)
  • Ensure adequate clinical notes are in the patient’s chart
  • Limit virtual practice to encounters that require only history, gross inspection and/or data that patients can gather with cameras and common devices (eg. Glucometers, home blood pressure machines, thermometers and scales), redirect patients to an in-office visit or acute health care setting if an in depth physical examination is warranted. (5)(2)
  • At the conclusion of the consultation, make extra effort to confirm the patient’s understanding of the assessment and plan, then arrange to send any prescription to pharmacies and any requisition or referrals to the patients or the appropriate office/facility. (7)
  • Collect/create patient education texts and weblinks to share after the encounter (5).
  • Complete the encounter note for the consultation, following the same standard as for a conventional visit.(5)

VI.   USING VIRTUAL CARE TO SCREEN FOR COVID-19

  • Prior to using Virtual Care, review and familiarize yourself the Public Health Agency’s case definition and related information on COVID-19 https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals.html
  • Familizare yourself with the COVID-19 guidance published by their respective provincial/territory guidelines or health authority
  • Screening for COVID-19 can be conducted virtually and doesn’t require an in-person physical examination. Virtual Care enables physicians to assess non-verbale cues while taking a history for screening purpose.
  • Virtual care by video offers the opportunity to assess the severity of the patient’s symptoms and determine the best care setting for the patient.
  • If a patient’s symptoms are mild, they can be managed at home. If not, the patient may need closer observation and treatment in a healthcare facility.
  • Using video, the clinical can elicit a history of:
    • Fever
    • Myalgia
    • Cough and /or
    • Shortness of breath
    • Observe if the patients looks unwell/ in respiratory distress
    • Is coughing
  • In the case where a clinician requires additional clinical information to determine a treatment plan ( ie 02 saturation, chest auscultation), the patient will need to be seen in person. If this is the case, alert the nearest care facility that the patient will be attending. (6)

VII.   ADDITIONAL INFORMATION

Please note that there are province-specific guidelines and resources for virtual care (e.g. billing codes, software guidelines, etc.) Please visit the Royal College of Physicians and Surgeons of Canada website for provincial telemedicine guidelines and resources (8).

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Ontario Telemedicine Network.COVID-19 Virtual Care Updates and Important Information [Internet]. OTN.ca. Available from: https://otn.ca/covid-19/. Accessed April 10, 2020
  2. Dermer Mark Dr. Joule COVID-19 Learning Series | Joule, a CMA Company [Internet]. [cited 2020 Apr 10]. Available from: https://joulecma.ca/joule-covid-19-learning-series. Accessed April 10, 2020
  3. OntarioMD. Virtual Care and the 2019 Novel Coronavirus (COVID-19) [Internet]. OntarioMD News. [cited 2020 Apr 10]. Available from: https://ontariomd.news/. Accessed April 10, 2010
  4. Australian College of Rural and Remote Medicine. How-to-do-a-high-quality-remote-consultation.pdf [Internet]. Available from: https://www.acrrm.org.au/docs/default-source/all-files/how-to-do-a-high-quality-remote-consultation.pdf?sfvrsn=86d02be8_2. Accessed April 9, 2020
  5. Canadian Medical Association. Virtual Care Playbook. Available from: https://www.cma.ca/sites/default/files/pdf/Virtual-Care-Playbook_mar2020_E.pdf. Accessed April 10, 2020.
  6. Ontario Telemedicine Network. Fact Sheet: Assessing Respiratory Symptoms via Video [Internet]. Available from: https://otn.ca/covid-19/. Accessed April 10, 2010.
  7.  Australian College of Rural and Remote Medicine. Organising Telehealth Services in Your  Practicehttps://www.acrrm.org.au/docs/default-source/all-files/organising-telehealth-services-in-your-practice-factsheet-final_v3.pdf?sfvrsn=2a5d74a_12. Accessed April 10, 2020.
  8. ‌Telemedicine and virtual care guidelines for health professionals | Royal College of Physicians and Surgeons of Canada [Internet]. Royalcollege.ca. 2020 [cited 2020 Apr 13]. Available from: http://www.royalcollege.ca/rcsite/documents/about/covid-19-resources-telemedicine-virtual-care-e?fbclid=IwAR3Zxg0Hk7lPr-Ugq8BqM-RodlVmzDJddoV_hhuf6PqHHe_cq3A0Gx40lRI

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.