There are plenty of reasons that face to face consultations are valuable, not only to provide examinations and procedures. The limbic link that connects people and that is so important in communication is dramatically filtered when made through a screen.
“Virtual first” processes allow for better infection control, and as a minimum patients and staff will expect excellent infection control in health services.
It will never again be acceptable to sit next to a coughing patient in a waiting room, or to be sneezed on when you are doing a diabetes check.
“Virtual first” also provides opportunities for improved access through the wider open door afforded by virtual systems and for efficient service delivery through planned consultations and direction to the best source of help.
To me, it’s a no-brainer. I know the concept of change is hard, and many GPs and hospital services just want everything to be back the way it was.
Unfortunately the way it was was not working for the most disadvantaged.
The way it was was not working for many primary care services and clinicians who were over worked, under paid, and frustrated with the quality of care they were able to provide because of poor access.
The way it was was not working for many rural communities.
Let’s see if virtual first approaches can make the way it was into the way it can be.
“Virtual First” is a movement to provide the usual and preferred first point of contact with the health system through a virtual connection.
This may mean a phone-call, triaging patients to the best pathway of care, a pre-consultation online webform, email, or patient portal message.
“Virtual first” extends to the delivery of healthcare through virtual tools, online messaging systems, email, telephone and video consultations.
“Virtual first” extends to home monitoring and outreach services.
It aims to:
reduce the number of times a face to face consultation has to happen between a health professional and a patient,
make best use of time by providing multiple points of access and flexibility
improve access through extended opportunities for contact between the patient and healthcare professionals.
direct patients along the most appropriate path for further care.
“Virtual First” primary healthcare is an opportunity to not only help us to separate potentially infectious people from others in the health system, it is an opportunity to address some of the fundamental issues that have challenged primary health care over the past two decades.
By providing a “virtual first” primary healthcare service we will be able to :
Increase the number and variety of access points to healthcare for the community
Increase flexibility around when services can be delivered
Increase opportunities for peer support and education
Increase effective advocacy through peer networks
Provide effective care with reduced costs to the system
We will also be able to triage patients so that staff and people using health services are less likely to come into contact with others who are potentially infectious.
What is Primary Heathcare?
The World Health Organisation defines primary healthcare through three key components:
Meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services;
Systematically addressing the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviours) through evidence-informed public policies and actions across all sectors; and
Empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and care-givers to others.
Virtual first primary healthcare applies the opportunities of the extended range of virtual tools we have to improve the effectiveness and efficiency of primary health care across all of these components.
What are the practicalities of virtual first primary health in response to COVID19?
Virtual Health for COVID19
Virtual health services could help you :
Reduce the chance of an unexpected case appearing in your practice – by enabling you to pre-assess patients before they arrive.
Reduce exposure of vulnerable people to infectious diseases – by providing safe and effective alternatives to face to face consultations in a health care facility.
Manage enforced staff absence from the workplace due to the need to self isolate or minor illness – by providing alternative ways they can use their skills from home.
Direct patients along the most appropriate path to access care.
Virtual Health services such as providing remote in box management, remote nurse tram support, remote consultations and pre-appointment triage are effective and safe ways to provide alternative access to care avoiding face to face consultations.
Practical Tips and Tricks:
Remote connection with the practice management system.
Setting up a remote connection from home to your Practice Management System is a bit of a faff, probably something you can’t do yourself these days, use a professional – contact your IT provider set up a unique login and be really mindful of keeping this secure.
Tool up.
Videoconferencing software on your mobile phone may seem enough, especially if you have an unlimited data plan, but we need to be a bit careful about security.
The NZ standards for health services are complex and legion. The NZ telehealth forum (https://www.telehealth.org.nz/) has lots of great information to help.
Services like doxy.me (https://doxy.me/) Vsee (https://vsee.com/) and Zoom for Healthcare (https://zoom.us/healthcare) meet USA standards for encryption and security, but this level of security is not necessary here. Many DHBs and PHOs are using Zoom “pro” accounts to host meetings and this provides an acceptable common standard, especially when hosted from an otherwise secure a computer system.
Your practice management system already has the ability to link videoconferencing between a patient portal and clinical staff. Get your PMS to switch this on.
Get prepared for dealing with potential issues – have information on hand about how to access diagnostic services, which alternative service providers are available in your area for immunisations, cervical smears, what NGOs and Hauroa services are available for dealing with youth, sexual and mental health issues and the services that are available to help address social determinants of health.
Get the team involved.
There is so much that you can do from home once you are connected it can be tempting to just try and see patients. This is fine, but it may not be the most useful thing you can do to simply replicate the same thing you’ve always done.
Ask you team what would be the most helpful thing you could to do to help.
You could reduce demand by doing phone triage, manage need by seeing patients with or without a nurse in support, free up colleague’s time by dealing with in box messages and tasks.
If you are new to virtual health, start small and review what you do regularly. Being there for clinic team may be enough. Whilst you are online checking results, having you available for a quick question or debrief can be hugely supportive for your clinic staff.
Think about your setup at home and don’t let this happen! When I first thought about virtual health I thought I would be sitting on the beach, or at a café – of course this is totally inappropriate and likely to lead to complaint – not only from your patient, but also anyone who happens to look over your shoulder and realises what you are doing.
We have taken huge pride in keeping health information confidential, now is not the time to show share open notes with everyone in Starbucks.
See yourself as others see you.
You can’t assume that the patient can see and hear you because you can see and hear them. Have a trial run, ideally see yourself as the patient will see you, if it’s unpleasant get the setup right.
You are an expert communicator and know that making eye contact helps connection, facial expression is a vital element of the consultation, for both you and the patient. The ideal is to have the patient record on the same screen as the video.
If you have to look away from the patient to see their records, tell them what you are doing so they know that when the main bit of you they can see is your ear that you are not staring out of the window.
Talk to the patient.
This is an unusual setting for a consultation and it’s good to be explicit about the expectations and limitations of the system and check that the patient is OK.
My video consultations usually start with me introducing myself and explaining “I am working from home, I can see your records, but when I look at them I need to look sideways, I can see and hear you clearly – can you see and hear me ok ? I know this is an unusual way of seeing a doctor, I won’t be able to examine you myself, but the nurse there will be able to help us. Are you OK with going ahead?”
Simulate your workspace at home.
Make remote working as much like working in your office as possible. You have a pattern to the way your work that keeps you thorough, and the patient safe.
Whilst you can cope with a different look and feel to the PMS on a smaller screen, even small changes can alter the way you use the system, fiddle with the display settings to get this right.
Be thorough.
Regulation and case law is going to take a while to catch up with virtual health. Patients are going to remember this interaction and if anything goes wrong they are more likely to raise a complaint or ask for an explanation because it has been an unusual process.
Be diligent in pre consultation – check recent records, past medical history, medication lists and allergies really carefully.
Record everything. When you are dealing with tasks make sure you record in the body of the notes what you have done, why you have done it and what actions are to be taken.
Write complete clinical notes – detail using the patient’s own words why they are consulting you, what their fears ideas and expectations are, who was in the room, what examination took place, how easily you could see, what was agreed as a plan for management or tests, and your agreed safety netting.
First you save yourself.
If you are actually sick, get well. Just because you can work from home doesn’t mean you should. Read a novel, write a poem, plant a few trees, play with your kids, chillax baby, being kind to yourself is essential professional development.
Computers are great tools, but knowing when not to turn them on is a vital part of learning to use them.
Be imaginative.
Being available to see patients alongside one of the other staff members is a massive opportunity to learn from each other, and for the patient to benefit from an interprofessional shared consultation – they get both the care and the cure.
You can support people doing home visits, see patients when they are overseas, manage multiple clinical sites.
The “New Normal” – looking forward to the next phase in healthcare.
The impact of the pandemic is going to be with us for the next 18-36 months if not longer, and whilst this is a challenge it is also an opportunity.
Moving backwards is rarely the right choice in medicine, and in this situation not an option.
We need to look forward to what is now becoming the “new normal” way we do things.
What won’t change ?
Primary care has been described as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”
It is measured as “good” against four elements:
First-contact access for each need;
Long-term person- (not disease) focused care;
Comprehensive care for most health needs; and
Coordinated care when it must be sought elsewhere
In some measures the degree of family or community care is also included. [1]
None of this is changing.
Nor is the fact that primary care is all about relationships.
General Practice team members are experts in relationships. We are experts in communication. We are experts in risk management. We are experts in healthcare.
Why do we need to change ?
For the foreseeable future we will be swabbing a large proportion of those who have respiratory symptoms for covid19, we will need to keep our other patients, and our staff safe from this disease.
There will be local and regional and potentially national outbreaks over this time.
This will be happening on the background of a world in economic crisis, challenges to businesses in all sectors, and a high level of patient and provider anxiety.
As a minimum we have to adapt to the “new normal” by :
Providing virtual triage for all patients to identify the potential covid19 from the non-potential covid19.
Having systems that keep infectious people away from others when we are seeing them face to face.
Providing safe systems to protect staff.
Having the ability to scale up a local response to manage an outbreak
Having systems for monitoring covid19 disease progress in the community and clear referral and management pathways
What is the New Normal ?
In the “new normal” general practice will continue to do what it does best with more virtual care, in cleaner environments with better infection control mechanisms, and with staff with more flexible working conditions.
In the new normal practices will need to either be “green zones” and have nothing to do with anyone with a respiratory infection or ‘flu like illness , or to have “green” and “red” zones and processes that allow them to continue to manage patients with respiratory infections and ‘flu like illness safely.
In the new normal “virtual first” becomes the primary point of contact for patients who need to use the health system. This will impact on the working conditions of all staff, as we shift our ability to provide effective efficient home based care.
In the new normal, personal protective equipment is worn, not kept in box in case of emergencies.
Community Based Assessment Centres (CBACs) have a role in supporting communities whose practices cannot provide “green” and “red” safe zoning, and to provide covid19 services to communities that have low GP penetration / poor access.
CBACs in the future have a role in stepping up to support practices dealing with an outbreak in a locality that threatens to overwhelm the local service. They will need to be able to be rapidly set up within 24-48 hrs, and to be in place for at least 28 days.
And the future ?
We have already demonstrated our ability to adapt to the new normal, as practices and as networks.
The new normal brings with it challenges and opportunities to do much more than just the bare minimum.
There have been palpable improvements in access to services through the switch to virtual care, yes with inequities evident; the digital divide is shown to be wider than was thought – but that’s just a problem, it’s not insurmountable.
There have been palpable improvements in working conditions for practice teams – yes, with challenges to the business model and income expectations, change in working patterns, and different stressors but these are just issues, they are not insurmountable.
Yes, we are worried that patient outcomes may be compromised somehow- but we have never been very good at measuring them and this is an opportunity for that to change.
Let’s embrace the new normal, look forward, learn from each other, build on the power of networks, and collaborate to provide better first contact, comprehensive, coordinated, person-centred care.
The commonest end point of a significant pivot in the way we do things is for us to return to our original behaviour over time.
Look at every new year’s resolution, every idea you bring back from a conference, even the range of medications you prescribe.
We don’t like change.
We lose focus on change that must happen over time, we don’t review and embed change.
We need others to help us, and we often rely on people who don’t really understand what needs to happen.
We lack commitment ourselves to see change through, we fail to inspire others to commit to change.
We lose energy and find it hard to maintain the effort required to embed change.
So why is the change caused by COVID19 going to be different?
SARS-Cov2 is not a short-lived phenomenon.
It emerged only in December 2019, NZ’s first case was in February, just 2 months ago. The graphs usually show an exaggerated bell curve, with a rapid fall in cases after a peak.
The rhetoric describes this as a fight. Wars are fought, battles are won and lost but eventually we will defeat this. We will “get through.”
The reality is that the only infectious disease that the world has managed to eradicate is smallpox.
Discussed from 1945, completed in 1979 this relied on a determined global campaign over 13 years, an effective vaccine, case identification, contract tracing and quarantine.
It is unlikely this illness will “burn itself out” as appears to have happened to SARS-Cov-1, this virus is much more infectious, and unlike SARS-Cov-1 does not appear to be limited in who it can affect.
“Herd immunity” (if achievable) is not a cure, it is an acceptance of prevalence.
Societal attitudes have changed.
Doctor’s waiting rooms have long been seen as a source of infection.
I am certain that every GP has had a patient in the past express that they don’t like sitting in the waiting room because it’s full of sick people.
This was usually dismissed with a shrug of the shoulders, a smile, a “What can you do, eh?”
Some of us would have apologised for keeping the patient waiting, assuming that was the underlying reason for stating of the blinking obvious.
There was an acceptance that risk was low enough, that consequences were minor, hidden or infrequent enough for us to dismiss.
We are now facing a “Semmelweis Moment.”
In 1847 Semmelweis recognised that handwashing reduced maternal mortality [1]. We have recognised that separating out infectious from non-infectious patients reduces transmission of COVID19 disease.
This isn’t new science.
What is new is our understanding of the need to change and we now need to act.
Semmelweis found it hard to ensure that cleaning hands between patients became the new normal, perhaps because change was imposed rather than developed through collaboration and engaging the hearts and minds of colleagues.
We are less likely to repeat that mistake because the general public will not let us.
More people across the world are contemplating routinely wearing face coverings, people are interested in the difference between aerosols and droplets, and the distance and speed at which viruses spread after a cough or a sneeze, they are asking questions about the length of time infectious particles can survive on plastic, metal, wood and paper.
It is never going to be acceptable again to sit in a place where lots of sick people have gathered and not to be provided with assurance that everything is being done to reduce transmission of disease between people.
It is unlikely there will ever be a cure.
History tells us that viruses and bacteria develop resistance to any “cure” we have created in the past, SARS-Cov2 is not going to be any different.
There may be medications that mitigate the impact of the disease, remdesivir and antiretroviral agents may interfere with viral replication, hydroxychloroquine and chloroquine may reduce the ability of the virus to enter cells, “convalescent plasma” containing antibodies generated by a person who has survived the disease may “boost” the immune system.
There is no doubt that we will develop better ways of intervening that will improve outcomes for people needing hospital care.
But it is very unlikely that we are going to be able to “cure” people of this illness with medication.
It is unknown if we develop or can induce long lasting immunity.
We hope that when we reach “herd immunity” either through a vaccine or natural immunity of 80% of the population, we will have reduced the risks to an acceptable level.
The fact is that immunity, whether vaccine induced or naturally gained is an unknown quantity.
If this coronavirus is like the others that cause 2o% of common colds, immunity may last 2-4 weeks, if it has similar properties to SARS-Cov-1 immunity it may last 2-3 years.
We don’t think the virus mutates as frequently as the influenza virus.
We don’t know if a safe vaccine will be found, or how long-lasting a vaccine will be.
What is clear is that vaccine development is not going to be quick.
The public response
Each year in New Zealand we accept that around 10 people will die from HIV, 20 people die from TB, we may not like it, but we accept that 2-3% of deaths in this country are due to lower respiratory tract infections.
COVID19 will become another blip in the numbers eventually, and its impact on healthcare will become part of the way we do things ‘round here.
People at high risk of other viral illnesses with no cure and no immunity, like Herpes and HIV, have changed behaviour to reduce the risk of catching and transmitting the virus.
This illness is going to gradually settle in the mind of the public into one of the risks that we take when we interact with others, but its global impact is not going to quickly go away in the mind of the public.
Although we rationalise the numbers of people who die each day from poverty, malaria, road traffic accidents, and medical errors the personal impact of seeing mass graves being dug in New York, the dying in hospital corridors in Italy, bodies in the street in Turkey that feels like this will stick.
The case load of SARs-Cov2 is following the same pattern of other respiratory infectious diseases.
We have seen a surge of known cases settle into a background incidence as a result of public health measures. It seems likely that this level of disease will flare and settle over time, both in the public consciousness and in the pressure, it causes on the health system.
How well we cope as a system will depend on the ability, we must keep that case load within the limits of the what the health system can cope with.
We may drift back to an acceptance of the risk when gathering to watch sports, concerts and theatre, to party and carnival, but the acceptance of risk is not going to extend to health care services.
Nor should it.
Dr Jo Scott-Jones FRNZCGP MMSc DipClinED DipSports DipObs DipGerMed
More reading on:
Change management
HBR item on DICE scoring (duration, integrity, commitment and effort.)
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