general practice

What is “Virtual First” Primary Healthcare ?

opotikigp Uncategorized

What does “virtual first” mean?

“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 :

  1. Increase the number and variety of access points to healthcare for the community
  2. Increase flexibility around when services can be delivered
  3. Increase opportunities for peer support and education
  4. Increase effective advocacy through peer networks
  5. 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: 

  1. 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;
  1. 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
  1. 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.

(https://www.who.int/news-room/fact-sheets/detail/primary-health-care)

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 :

  1. Reduce the chance of an unexpected case appearing in your practice – by enabling you to pre-assess patients before they arrive. 
  2. Reduce exposure of vulnerable people to infectious diseases – by providing safe and effective alternatives to face to face consultations in a health care facility.
  3. 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.
  4. 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:

  1. 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 privacy.

If you haven’t seen the BBC interview where the US diplomat’s 3 yr old daughter interrupts his interview – watch it now. (https://www.youtube.com/watch?v=IKxqy9SJ-0I)

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. 

  1. 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.

Sharing the Joy of General Practice

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In an effort to counter the weight of negative sentiment about being a GP that I see in social media I have decided to collect and share some of the positive stories I hear all the time from colleagues about what it is that brings joy into this amazing job.

The New Zealand General Practice Podcast is the result.

It’s a bit rough and ready – created using Anchor and recorded just on an iphone, the interviews grabbed wherever I can find people willing to share their stories – conference halls, airport lounges, over cups of tea in common rooms. There’s a bit of background noise !

It has been fascinating considering the many and varied roles that GPs play in their communities to find there are a number of themes, and much  common ground between GPs urban and rural, and with their rural hospital specialist colleagues.

To me this reinforces the value of having the Division of Rural Hospital Medicine within the scope of the Royal New Zealand College of GPs, and speaks to the potential for the RNZCGP to expand further and align all professions working in primary care. We have more in common than we have differences.

It’s also been very heartening talking to students and young doctors about what would draw them towards a career in general practice to see how closely aligned that is with the lived reality shared by experienced GPs.

What brings Joy to you in General Practice ?

@opotikigp

Wonca World Rural Health Conference Gramado April 2014

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The WONCA WORKING PARTY on RURAL PRACTICE is the rural working group of the world organisation of academic associations and national colleges.
Amongst other work it runs regular conferences and Gramado in Brazil was host to the 12 th WWPRP conference.

The picture above is of Carlos Grossman and his wife Doris, he was heralded during the conference as the father of family medicine in Brazil, I spoke to him about why as a cardiologist in the 1970s he had decided to set up a family medicine programme.

His response was both simple and profound : ” We need to be close to the people.”

Is there a better explanation ?

Rural people are disadvantaged from the outset because of distance, Carlos Grossman recognised it is essential to have health care that is provided close to the people, by a professional trained to engage closely with them in their work and family life, a professional who shares the closeness of the community. This shared experience, also identified by McWhinney as a essential part of family practice, brings with it opportunities for fantastic work in supporting people to live happier and healthier lives.

It is a phenomenal thing to come to a realisation that the culture you work in as a GP is substantially different from that of other GPs, and the question of what it means to be a “rural” GP is worth a later exploration, suffice to say being able to spend time with like minded but different people, with a richly diverse way of dealing with a common set of challenges was not only interesting but I suspect will prove useful in the New Zealand context.

My task now is to share some of the ideas that were shared with me during the event.

For those of you who “twitter” searching through my recent tweets using #nzrgpn you will be able to find slides and comments from the main speakers.

Consider following me @opotikigp and @ruralwonca for future links and conversations about rural health.

First Post -Truth develops over Time

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Don’t shoot the messenger.

The purpose of taking this step into bloggersphere is to provide another outlet for my own opinions about the state of healthcare, in particular how rural communities, and in particular rural communities in New Zealand, fare.

I suspect that when Don Berwick and his colleagues delivered their Don Berwick’s report for the UK NHS they felt a bit like Phiddepides the apocryphal first marathon runner.

Phiddepides bore bad news of invasion, and of the failure of the government of the day to respond.

Berwick et al told the bad news to the UK government of the need for systematic and widespread change to address the failures of the health system, to develop a culture of learning and patient safety, and the letters he wrote, to management, staff and the public exhort a response. They not only challenge the system in England, but internationally. Have we responded?

Famously Phideppides died at the end of his courier run, conveniently I suspect, since the bearers of bad news often did not fare too well in ancient times.

Many bearers of bad news are still “shot down” at least metaphorically, and perhaps in an effort to avoid this people who challenge the status quo will couch their approaches as “solutions” spinning the bad news to assuage the anxieties of leading political parties.

The problem is it is almost impossible to keep everyone happy all the time whilst maintaining the feeling of freedom of expression.

I have been told that you need to play the game if you are to have influence, to treat the powerful like they are children in a sandpit, fighting for the bucket that makes the sandpies.

It seems to me that a regular personal viewpoint, expressed clearly and with the acknowledgement that it is often through expressing ideas and debate that opinions form, could help to get the message through to the children in the sandpit.

Here’s hoping they don’t shoot….