Authors: Fadi Bahodi, Justin Hall
As you begin envisioning virtual care in your hospital, you begin to wonder about the details of your program. How do you funnel patients to where they need to be, and how do you ensure that patients receive the care they need? Furthermore, how do you ensure that these processes are cohesive and well structured?
Welcome to the second part of the HiQuiPs introduction to virtual care series! In this post, we will delve into the details of these processes in a virtual care program and highlight areas where challenges or complexity may arise. You can view part 1 of our introduction here.
The virtual care process
While each virtual urgent care program is unique, they are unified by a common set of principles.
The virtual urgent care process has 5 main principles:
Marketing and communication
Patient navigation and registration
Triage
Care provider interaction
Post visit follow-up
Each of these aspects is complex, requiring careful consideration and planning before implementation. For example, if a registration and scheduling system is too complex and not user-friendly, patients may abandon the process midway, or if encounter charting is not readily accessible to patients and their longitudinal providers, patients may be lost to follow-up.
Virtual care before patient interaction
There are several important considerations to make the virtual care experience of high value for patients, even before they use the platform. For example, communication and marketing materials need to be shared using plain language and accessible through a variety of platforms (such as web pages, social media, traditional media, departmental posters, family physician offices, handouts) to reach a diverse audience. Furthermore, the system needs to stratify patients based on risk to ensure virtual care is an appropriate option based on their primary concern. Virtual care services must also integrate with existing care pathways and primary care services so as to not further silo or fragment patient’s care; sharing of visit records within one’s circle of care is essential. Finally, a robust mechanism to track and monitor patient safety and healthcare utilization data are essential elements as part of continuous quality improvement efforts.
How do patients move through the virtual ED system?
Virtual care programs in emergency departments tend to have three stakeholder groups: patients, providers, and administrators. At the forefront, patients access an online application through a website or a web portal. From here, they are prompted to enter information and answer a series of questions to assist with triage and to help inform ongoing quality improvement and research efforts. Basic demographic information, previous health history, current symptoms, and chief complaints are solicited and sent to administrative staff to facilitate patient registration and scheduling. Whether through posted clinical guidance, self-triage and administrative review, or nurse-triage, platforms generally have a way of alerting patients with high-risk concerns that they should present in-person to their nearest ED rather than waiting to be seen virtually.
The intake form
The general process always begins with an intake form, which can be used to triage and place patients where they need to be. The intake form that patients complete may be relatively long, as it collects patient demographic and health data including their chief complaint or reason for presenting. Systems need to balance obtaining sufficient patient data in advance of an appointment and patient convenience, as both directly influence engagement and potentially health outcomes.
Triage
Following completion of the intake process, each healthcare system has a slightly different approach. A common approach is having an administrator take the patient’s responses, enter it into the local registration and scheduling systems or electronic medical record (EMR), and then book an appointment. The triage step in this process is often complex and differs between institutions; the effectiveness of each approach is just beginning to be studied.(1, 2)
Nonetheless, an important challenge in any virtual care encounter in the ED is triaging “gray” cases. The Canadian Triage and Acuity Scale (CTAS) provides guidance for how critically ill patients are, with CTAS 1 and 2 being the most critical and are directed to come to a physical ED, whereas CTAS 4 and 5 are more minor presentations and generally appropriate for a virtual urgent care visit. CTAS 3 represents a gray zone between the two, with some patients requiring an in-person assessment in the ED while others are appropriate for a virtual care setting. Virtual programs need to have protocols in place to ensure these patients do not fall through the cracks, while also keeping the system as efficient as possible.
The physician encounter and beyond
The care provider, usually a physician, then receives a schedule notification with a link to meet the patient. The patient also receives the same link, from which they can both discuss the current presentation and management plans. If a patient is unable to navigate any step of the process, administrative personnel are available via phone or email to help facilitate pre-visit registration, connection difficulties, or post-visit care.
For many patients, no urgent follow-up is required as their concern is addressed during the virtual interaction, while others may have a prescription faxed to their preferred pharmacy. For other patients, relevant testing may be initiated virtually and the patient may be encouraged to follow-up virtually or in person after test completion. Finally, patients with higher risk symptoms/complaints may be directed to the ED for further assessment and testing. In all cases, visit records should be provided to a patient’s family doctor to help ensure optimal continuity of care.
Next Steps – more than just faster triage
Each part of the process has room for refinement. Programs can adopt more human-centred design as data becomes more available, helping to ensure patient engagement and autonomy. Triage can be optimized with emerging AI technologies, and new channels of communication can be implemented to streamline care.(3)
You draft a patient flow diagram for a virtual care pathway at your institution. After getting feedback from some colleagues in nursing and hospital administration, you will bring up your plans at your next departmental meeting to assess buy-in towards moving forward in the design process.
You now have an understanding of the main processes that are shared across virtual care programs. Stay tuned for our next month’s post where we discuss delivering compassionate care in the virtual ED. Let us know what you think on Twitter at @Hi_Qui_Ps. If there is anything specific you would like to learn about, e-mail us at hiquips@gmail.com. There is more content to come on Health Informatics and Digital Health!
Senior Editor: Shawn Mondoux
Copyedited by: Fadi Bahodi
References
Croymans D, Hurst I, Han M. Telehealth: The Right Care, at the Right Time, via the Right Medium. NEJM Catalyst [Internet]. 2020 December 30. Available from: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0564
Rademacher NJ, Cole G, Psoter KJ, et al. Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine. JMIR Med Inform [Internet]. 2019 May 8:e11233. Available from: DOI:10.2196/11233
Desruisseaux M, Stamenova V, Bhatia RS, Bhattacharyya O. Channel management in virtual care. npj Digit Med [Internet]. 2020 March 25. Available from: DOI:10.1038/s41746-020-0252-4