Virtual Patient Care

New: Check out this new Virtual Care handbook and resource website created by past CMR Dr. Leora Branfield Day and collaborators.

In the COVID-19 era, much of ambulatory care is now being delivered virtually. Although inpatient visits have been ramping up, you will find that a bulk of your ambulatory clinics (i.e., AACU not included) have been converted to virtual (video or telephone) visits.

There are many logistics to consider when providing virtual care — faxing prescriptions directly, obtaining bloodwork, deciding when you need an in-person assessment/exam, etc. Although this might sound initially daunting, you will learn many valuable and professional skills and will become more comfortable with virtual care with just a little practice! Having now done this for several months, your attendings and clinic staff are very comfortable with the virtual workflow and are a great resource if you have questions.

Here are a few general guidelines for providing virtual care.

On Day 1 of The Rotation:

Sit down with your staff to walk through a patient encounter and see how they like to run things. This might include:

• When/how/where to videoconference or phone the patient
• How to chart review / which Epic dotphrases to use
• How to obtain consent for virtual care (and how to document this – there’s a dotphrase, .covidtele)
• How to chart during the encounter (this is an advantage of virtual care — you can often chart synchronously!)
• How to review the consult with your staff — e.g., in person or over the phone
• How to close the encounter with the patient — e.g., through a three-way conversation with your staff, or staff phoning the patient themselves while you move on to the next patient
• How to complete post-encounter tasks including bloodwork requisitions, prescription faxing, follow up appointment booking. etc., and whose responsibility this is
• How to get an EPA completed (if this is a requirement for your training)

BEfore and At the Start of the Patient ENCOUNTER:

• Make sure you have a private space to have the video or audio visit (ideally, a clinic room)
• Make sure your patient has a private space to have the video or audio visit. When you start the encounter, clarify with the patient if they are comfortable beginning the visit in their current location.
• If you are videoconferencing and see someone walk into the room behind your patient, always pause and ask if it’s okay to continue.
• If you are calling from the hospital, use a clinic phone (ask clinic staff for long-distance code if needed). If you are using your cellphone, make sure you block your phone number first.
• Have a backup plan: If Zoom isn’t working, you may have to convert to a phone visit. If you are unable to reach the patient, ensure that there is a follow up plan (e.g., getting clinic staff to try to reach patient, rescheduling phone appointment, etc.)
• Start by obtaining consent and establishing ground rules. A sample consent script is below:
  “Just like online shopping or email, Virtual Care has some inherent privacy and security risks that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in this virtual care encounter in a private care setting (and should not use an employer’s or someone else’s computer/device as they may be able to access your information)1. If it is determined you require a physical exam you may still need to be assessed in person. You should also understand that virtual care is not a substitute for attending the Emergency Department if urgent care is needed. Are you ok to continue?”

AFTER THE PATIENT ENCOUNTER

• Ensure you document the start and end times of your virtual visit in your note
• Review with your staff (the logistics of reviewing may vary by clinic)
• Complete your note and any after-visit tasks (prescriptions, requisitions, orders, etc.)
• Ensure that a follow-up plan (discharge from clinic, follow up in-person, follow up virtually, etc.) is created

Virtual Teaching

You will attend a mix of virtual and in-person teaching (largely the former) depending on the type of session (small-group vs. large group, subspecialty vs. core, etc.). Here are a few tips on getting the most out of virtual teaching:

• Most virtual teaching happens over Zoom, with a minority taking place on Microsoft Teams. Check your email and our online teaching schedule for up-to-date links and passwords.
• If possible, try to have your webcam on! It is very challenging teaching to empty boxes on the screen, and being able to see faces makes a huge difference to the person teaching. All clinic rooms are equipped with webcam-enabled computers, and/or you can join on your cellphone.
  • If you don’t have access to video-enabled devices, please let your CMR know and I can work on this for you.
  • If you don’t want your background visible (totally understandable!), the Zoom virtual background is a great way to have only your face visible
• Put yourself on mute if you’re not speaking. Pro tip: You can keep yourself muted and press the spacebar to unmute when you need to speak.
• Almost all our teaching is interactive, so please jump in! Your session facilitators may ask you to unmute and speak, or use the chat function, or use the ‘Raise Hand’ function.
• Keep in mind that your session facilitator may have a hard time seeing the chatbox or a raised hand if they are screensharing or presenting. If you notice that you or your colleagues have a question that hasn’t been attended to, unmute yourselves and chime in!