Virtual Visit Guidelines

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.

Resources

Adapting to Virtual Care

AAMC

An iCollaborative posting for Telemedicine OSCE (TeleOSCE) Educational Cases - Sinusitis, Knee Pain, and Foot Sore-Diabetes

Clinical Teaching & Learning Experiences without Physical Patient Contact (Virtual Rounds Webinar). View here 

Academy of Communication in Healthcare

Telehealth Communication: Quick Tips

BMJ

Covid-19: a remote assessment in primary care

Canada Health Infoway

Virtual Care Resources During COVID-19

Canadian Family Physician

Telehealth and patient-doctor relationships in rural and remote communities

CMA/ CFPC/ RCPSC

Virtual Care Playbook, March, 2020. Med Ed Working Group, page 35-39. Competencies required to deliver virtual care – Appendix II page 46

Canadian Medical Protective Association

Covid-19 Hub; including on Telehealth and virtual care

 eHealth Recommendations

 Videoconferencing Guidelines

College of Family Physicians of Canada

Archived Webinar: The COVID 19 Pivot- Adapting our Practice to Virtual Care (start at the 7min 30 sec mark, advice for residents starts at 44 min)

Faculty Development Resource Repository

Doctors of BC - Doctors Technology Office

Virtual Care Quick Start Session for Physicians in British Columbia (webinar recording)

 Virtual Care Quick Start Session for Physicians in British Columbia (pdf)

 Virtual Care Toolkit (pdf)

McGill University

Telemedicine Online Module

Virtual Medicine Resources

Teaching Telemedicine

CMPA Info on Virtual Medicine

Northern Medical Services

Advice from James Purnell

Red Whale - UK

Remote Consulting: A Survival Guide

Dr. Cassie Millar's Virtual Care Peer2Peer Network Facebook Page

An interesting discussion board with mostly family physicians sharing tips on and asking questions about how to get virtual services going quickly.

Karen Hyder, Melissa Chambers & Tammy Olson

View this helpful planning & delivery preparation checklist for virtual teaching: 'The Art & Science of the Virtual Classroom'

Telemedicine Policies & Guidelines

College of Physicians and Surgeons of Alberta

Virtual Care guidelines related to COVID-19 for the province of Alberta

College of Physicians and Surgeons of Saskatchewan

Policy on Telemedicine. Additional guidance and resources, including for delivering virtual care during a pandemic, are available on the College’s website.

Royal College of Physicians and Surgeons of Canada

Telemedicine and virtual care guidelines (and other clinical resources for COVID-19) – Saskatchewan information

US Telehealth Planning Guides

American College of Physicians

Telemedicine: A Practical Guide for Incorporation into your Practice (Released March 18, 2020) Free online curriculum, ACP.

California Telehealth Resource Center

CTRC’s Telehealth Program Developer Kit

Supervising Residents

College of Family Physicians of Canada

Tips for Supervising Family Medicine Learners Providing Virtual Care

Emerging Topics Bulletin for Educators: Pearls for Writing a Virtual Care Field Note

NOSM, CEPD

Supervising Learners While Providing Virtual Care

Royal College of Physicians and Surgeons of Canada

Virtual Teaching Resources - New eSupport Email Series.  The Royal College will be sharing a series of resources via email that can be used to support safe resident learning.

Orienting Residents to CBD

CBD Online Learning Modules, including Coaching to Competence & Entrustability Scales

Remote Faculty Development: Key CBD Resources – is a curated at-a-glance list of CBD faculty development resources that can be taught remotely. It helps ensure you cover all of the key topics and it gives guidance on which resources are most appropriate for different audiences and for different remote delivery methods.

USask

A PowerPoint on the 'Supervision of Residents During Virtual Care'. This presentation was adapted from CFPC guidelines.

USask

Direct Observation Remote Virtual Patient Encounter Form.  This form can easily be adapted to fit your programs needs.

For Patients Receiving Virtual Care

Institute for Safe Medical Practices Canada

How to Prepare for a Virtual Meeting with Your Healthcare Provider