Brigham and Women's Hospitals

Virtual Care

Virtual Visits

Resources for Virtual Visits

  1. Brigham IS Virtual Care Resources
  1. Virtual visit tools, training and billing information
  1. The transition to telemedicine/virtual visits has many details (not just technology, but payment, regulatory, consent etc) and is a new clinical interaction for many providers. It is also an area in which there are some rapidly changing areas (esp what is covered, esp with commercial payors). There are some very helpful omnibus resources and your local medical society will have updates regarding state regulation. The purpose of this section is not to replicate that but to provide distilled links in important areas, and to share pragmatic guidance from the lived experience of practicing primary care providers. (Please note: we are general internists, and so this is not as comprehensive as needed for Family Medicine practitioners)
  2. Important omnibus resources for primary care include:
  1. CDC COVID-19 Ambulatory Care Settings guidance
  2. AMA COVID-19 Resource Center and Quick Guide to Telemedicine Practice
  3. ACP COVID-19 Physician's Resource Guide and COVID-19 Practice Management Resources
  1. The Telehealth Resource Center links to local regional telehealth organizations which often curate/provide locally specific telehealth resources including telehealth training resources (e.g. for the NorthEast including MA)
  2. For Massachusetts where we practice:
  1. Mass. Medical Society COVID-19 resources - see the Telehealth and Virtual Care section
  2. The Telehealth Resource Center Northeast Corner Center is NETRC and their Resource Center offers many telemedicine resources, including telemedicine training, best practices and a telehealth toolkit.

Payment, Regulations, and Policies

  1. Payment for virtual visits
  1. These vary by state and payor (but many will likely follow the Federal Medicare changes). Practice administrators can track these via the AMA (Policy, Coding & Payment tab), ACP, the Center for Connected Health Policy Telehealth Coverage Policy tracker and their local medical society (for us in Massachusetts this is the Mass. Medical Society).
  1. Regulations regarding virtual visits
  1. These also vary by state and payor. The same resources above apply. There is also a legislation and regulation tracker from the Center for Connected Health Policy.
  1. Local Policies regarding virtual visits
  1. At this time, the major local policy change has been the switch to virtual visits for all patients, the closure of most clinics, and the creation of specific "physical visit" clinics such as respiratory clinics and the non-respiratory urgent care clinics with specific requirements required for patients to be referred there (primarily a requirement to do a COVID screen, medication reconciliation, and order any pre-visit studies) and for the primary care provider to be responsible for followup (with the expectation of an satisfactory handoff - which has been limited with the current note based EMR). This will likely rapidly evolve and we will update this section with additional guidance.

Preparing for a Virtual Visit

Scheduling

  1. If the visit is to be changed to a virtual visit, our practice assistant will then:
  1. Change the visit type (this changes the encounter type, if video, a small video will appear in our schedule (note: this is a column we have to activate individually))
  2. Contact the patient to:
  1. Let them know about the change to a virtual visit
  2. Ask them if they consent to the virtual visit
  1. If they consent they are directed to complete our consent online, either in the patient portal or via an online site.
  1. Let them know that their provider will contact them within 15 minutes from the start time
  2. Give them instructions on downloading the correct software. For eg. here are our patient virtual care instructions
  1. To prepare our providers we have created a Virtual and Phone Visits page within our primary care wiki (login required) that gives detail for them on the setup and documentation required for each of the visit types.

Visit Types

  1. Phone visit (used most frequently at this time, many patients have preferred this over video)
  2. Integrated Zoom Visit (system is embedded in EMR)
  3. Standalone video - using a video platform outside the EMR, but documenting the visit in the EMR (You should confirm the appropriate setup with your legal/compliance prior to using)
  1. Zoom with specific settings:
  1. HIPAA compliant version of Zoom (requires enterprise license, minimum monthly fee, they will sign BAA)
  2. Enable waiting room
  3. Disable cloud recording
  1. Doximity with a video dialer
  2. There are many other standalone video services and CMS notes that platforms such as FaceTime can be used as well

Staff training

  1. It can be very helpful to have specific staff members trained to support your providers in a just-in-time fashion. We are using Microsoft Teams and have created a "Clinic team" with a support channel called "Support - Ask Anthony" with one of our local tech savvy staff members who can provide support in real-time. Teams allows us to get real-time notifications, and allows us to screen share to help solve problems quickly. In addition to a traditional support desk, our organization also has a dedicated EMR support phone line.

Virtual rooming

  1. We are not currently using this but other organizations have used technology or staff (such as medical assistants) to help with virtual rooming including:
  1. Asking if the patient is able to check vitals at home such as BP
  2. Confirming medications
  3. Doing some initial standard screening questions ~ such as asking about fevers, exposures, safety, food, housing and medications. PHQ2 can also be included.
  4. Establishing the time available for the visit, and helping prepare the patient with specific issues or questions they would like to address

Including other people

  1. For many of our patients, caregivers at home will be really important to their care. Video visits can give you the opportunity to include them in your visit.
  1. Consider having your practice assistant ask the patient "is there anyone else you would like to include in the virtual visit" when they schedule the appointment
  1. If yes, then that person should be called and given the time and how to access the meeting
  1. During the visit, you can admit the patient first, and then confirm
  1. Would they like to have the other member present throughout the meeting (admit them immediately)
  2. Or, would they like them present for the plan only (admit them at that time ~ you should confirm that this person might not have important information that would inform/alter the plan)

Provider preparation

  1. Preparation is similar to existing visits, with a chart review of interval events, and updating the previous active plan.
  2. I use a virtual visit note template, which I update prior to the appointment.
  3. The ACP has a very helpful telemedicine checklist.
  4. Create a professional setting:
  1. Appearing professional in your video visit requires attention to (1) your clothes, (2) lighting, (3) your background
  1. Lighting
  1. It is helpful for your patient if you are well lit. A front facing light can be helpful. A diffuse light will be more helpful than a focused light. A bright backlight will make your face appear dark.
  1. Background
  1. Your background will be visible to your patient. When you see your patient, this can give you insight into your patient's home environment. This now can also apply to you.
  2. Check your background before the visit (enter a virtual meeting alone with your camera on)
  1. Check if the software offers virtual backgrounds
  1. Zoom - click the arrow next to video, choose virtual backgrounds
  2. Microsoft Teams - click the … in the control bar, and choose "Blur background"
  1. You can consider purchasing a japanese screen or using a temporary curtain
  2. You can use an external camera and place it in a position that gives you a neutral background

Performing Virtual Visits

Connecting

  1. For telephone visits
  1. Reaching the patient:
  1. Dial the patient's number from the chart (this should have been verified/confirmed by your practice staff when making the appointment).
  2. If you do not have a clinic provided phone, Doximity offers a dialer which will call the patient with the clinic number listed as the originating number.
  1. If unable to reach the patient, I generally try their cell phone next.
  1. If unable to reach, I try again in 5 minutes
  2. If still unable to reach I then leave a message asking them to call my clinic to reschedule the visit.
  1. Use a microphone and headphones with your phone for a few reasons:
  1. You can be handsfree allowing you to take notes
  2. It usually has better sound quality for your patient
  3. It picks up less background noise
  1. For video visits, it can be platform specific. For the most common scenario of standalone visits we follow this:
  1. Starting the visit
  1. Launch the platform, go to the specific "virtual room" / start the meeting
  1. The patient may already be in the waiting room -> admit the patient
  1. If the patient is not present, then I dial the patient by phone:
  1. Sometimes they have had issue connecting, if I cannot help solve them I use the just-in-time support staff member described above)
  2. Given limited time, if it takes more than 2 minutes, we will generally convert to a phone visit.
  1. It can be a good idea to use a microphone/headset:
  1. It usually has better sound quality for your patient
  2. It often picks up less background noise
  1. Confirm the identity of the patient
  1. It is important to use 2 identifiers
  1. "Mr X, it's really good to connect. Because we are using this new kind of visit I do need to have you confirm 2 identifiers for me. For my records, can you please just state your full name and date of birth?"

History

  1. Common questions for all patients:
  1. As part of my first virtual visit with my patients I ask:
  1. Any symptoms concerning for COVID
  2. Any exposures or concerns re exposures to COVID
  3. Do they understand / are they able to be safe during COVID
  4. Who is at home with them?
  5. Have they been affected financially by this?
  6. Do they have enough food?
  7. Do they have their medications?
  1. I also do a quick assessment of the risk status of this patient (for complications from a COVID infection) - see the criteria for high risk
  2. I confirm their health care proxy and address goals of care for all patients

Examination

  1. While the same physical examination cannot be done, as noted in the ACP Telemedicine checklist objective assessment of some elements can still be done:
  1. By phone
  1. General distress
  2. Clarity of thought and speech
  3. Ability to speak in full sentences
  1. By video
  1. General appearance
  2. Skin tone and rashes
  3. Clarity of thought and speech
  4. Eye redness / icterus
  5. Respiratory Rate / work of breathing
  6. Gait / Tremor
  1. With patient assistance
  1. Self palpation
  2. Range of motion
  3. Close up camera views of oropharynx
  1. Home monitoring device results:
  1. Blood pressure
  2. Thermometers
  3. Pulse oximetry
  4. Glucometers
  5. Peak flow