What do we know, what are best practices, where can I learn more, how do I teach this?

We are adapting to a new environment for patient care.  Phone calls and videoconferencing with patients has been occurring in the delivery of medicine at increasing levels over the past decade. Telehealth is a tool that can include phone (basics) or video (more advanced).  This tool allows us to hear the patient’s story and 80% of making a diagnosis is about good history taking and these approaches to care can still be effective using the right skills.

Virtual visits are a common model used for distance care in rural and remote areas but there are also numerous examples of groups of physicians providing virtual care in urban areas, following methadone patients, for follow up, etc.  Physicians all across Canada in academic and FFS practices, are now engaging in virtual care visits, developing new skills to continue to provide good care under unusual circumstances.   These visits are widely used in SK by many specialties including psychiatry, dermatology, oncology and by pediatric intensivists, etc.

Virtual Care guidelines, workflows and consents

Make sure you are comfortable and have set up your phone/computer/laptop so that you have as ergonomically ideal set up as possible – this may involve creating a standing computer set up.  You also need to think about the position of the camera on your computer – you want to be looking at the patient ie achieve the best you can for eye contact.  You may also want to set up your computer so you can see the patient’s chart and sometimes this means using two screens if this is an option.  Screen management should be thought of in advance of the visit.

Use the time between visits to MOVE around; stretch, dance, walk – all can help with your physical and mental health.

In video visits – you need to consider your appearance, your “comport” online and maintain a high level of professionalism.  Some suggest wearing a white coat for these visits to establish a clinical tone despite the distance or the informal nature of seeing a patient in their home. During COVID-19 pandemic, many issues might be covered in a virtual visit but we have to remember that not all visits are suitable for this and sometimes we need to arrange to see our patients in clinic.  Use this time appropriately and encourage patients to come in for appointments when needed.  If you are teaching, you can discuss this with your learner in a 'huddle' before the patient visit starts.

Introduce yourself and confirm that you are connected to the right patient.  For virtual visits, it can very useful to have a family member present during the visit.

Consent – Verbal consent is okay. For video visits – you can include the consent in the visit. It’s important to clarify if anyone else is able to hear and if it is okay with the patient. This is not dissimilar to when a patient is accompanied in the examining room at an office visit. Consent can also be taken during scheduling the appointment by an admin assistant if it is an option, this will save time.

When first engaging in a virtual visit with a patient who has not done this before, it is important to acknowledge this; to state it explicitly and explain why it is important.  “We're in this together.” Virtual visits are a means of offering what we can under the current pandemic circumstances. These visits are easier when you/ your supervising physician/ and the clinic have a past relationship with a patient but they can be done even when the physician has no formal previous relationship with the patient.

The visit

What is most suitable for virtual visits?

Mental Health	Derm	STI Screening	Travel med	Some CDM
Contraception Counselling	Simple UTIs	URTI/ usual coughs and colds	Other straight forward infections	Follow up and monitoring/ routine screening

You need to use active listening skills and convey empathy as appropriate. These visits are not suitable when a physical exam is needed and an in-person visit may be required.   We can be upfront about the compromises needed in practice at this time and explain the limitations of virtual visits.  In addition most follow-up visits can be done virtually with some exception. Document in the EMR as you go as you would with an office based visit.

Objective data you may be able to acquire during a virtual visit include:

Home BP Readings	Temperature	Breathing	Visual Inspection
Weights	Pulse	Glucometer Readings	Facial Expression

It is important to observe closely and carefully and make note of any of the above as well as tone of voice, emotional state, etc.  Verbal and nonverbal communication is still important and core aspects of virtual visits.  When using video, you can assess mobility/frailty by asking the patient to stand up and walk (if there is enough space in the room).  You should explain your rationale before doing this but observing the patient get up and move can be very helpful.

Diagnostic reasoning is important as you think through the hx, PE, assessment (including a ddx) and your management – same as any visit. You can also use other tools during the visit – Up To Date, etc.  “Smartphones are the Swiss Army knife of virtual visits.” (John Pawlovich)

In our management, try to provide therapeutic dose of compassion, de-escalate stress and create the trust and rapport needed for a therapeutic alliance. Use empathy and a patient centred approach in finding common ground.

Remember to ensure all scripts are discussed and completed in the EMR. Verify any other issues to address before you disconnect.  Time management is important without rushing if there are back to back virtual visits.

If you are working with a resident, ensure you review the visit, provide appropirate feedback.  Ensure prescriptions are sent and all forms/ tests/ consults are completed.  Arrange follow-up as needed.

Your comfort with doing these types of visits will improve over time. It is like learning any new skill, there is a learning curve but it is generally felt to be a short one! Virtual care is an evolving field with applicability in the delivery of primary care in Canada beyond this pandemic so it is a valuable skill to learn as it will have future applications in your practice.

References

This content was adapted primarily from the CFPC archived webinar 'The COVID-19 Pivot-Adapting our Practice to Virtual Care, 2020. Mark Dermer, John Pawlovich, Jeff Sisler. https://vimeo.com/401360939

Coiera, Enrico. "Essentials of Telemedicine and Telecare." British Medical Journal 324.7345 (2002): 1104. Web.

Greenhalgh, Trisha, Gerald Choon Huat Koh, and Josip Car. "Covid-19: A Remote Assessment in Primary Care." BMJ 368 (2020): M1182. Web.

Sharma, Rahul, Sapir Nachum, Karina Davidson, and W. Nochomovitz. "It’s Not Just FaceTime: Core Competencies for the Medical Virtualist." International Journal of Emergency Medicine 12.1 (2019): 1-5. Web.

Toh, Nathan, John Pawlovich, and Stefan Grzybowski. "Telehealth and Patient-doctor Relationships in Rural and Remote Communities." Canadian Family Physician Medecin De Famille Canadien 62.12 (2016): 961-63. Web.

• Virtual Care for Residents (PDF)