Advice and resources to assist you in offering virtual care.
Dr Jo Scott-Jones, Pinnacle clinical director explains what this means, and shares some of his practical tips and tricks he's learnt from practicing virtual medicine.
"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:
"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 healthcare over the past two decades.
By providing a "virtual first" primary healthcare service we will be able to:
We will also be able to triage patients so staff and people using health services are less likely to come into contact with others who are potentially infectious.
The World Health Organization defines primary healthcare through three key components.
Using the range of virtual tools we have in primary healthcare is a real opportunity to improve the effectiveness and efficiency of primary health care across all three of these components.
Virtual health services such as providing remote inbox management, remote nurse team support, remote consultations and pre-appointment triage are effective and safe ways to provide alternative access to care avoiding face-to-face consultations.
Setting up a remote connection from home to your PMS can be difficult and is probably something you can't do yourself these days.
Contact your IT provider, set up a unique login and be really mindful of keeping this secure. Ask about security and as a minimum set up two factor identification.
Video-conferencing software on your mobile phone may seem enough, especially if you have an unlimited data plan, but we need to be careful about security.
The New Zealand standards for health services are complex and legion. The New Zealand telehealth forum has lots of great information to help.
Services like doxy.me, Vsee and Zoom for Healthcare meet US standards for encryption and security, but this level of security is not necessary here. Many Hospitals and PHOs are using Teams or Zoom "pro" accounts to host meetings and this provides an acceptable common standard, especially when hosted from an otherwise secure a computer system.
(The Clinic and Professional (paid) versions of doxy.me use Stripe as their payment gateway to process credit card transactions. Stripe charges 2.9% + $0.30 per transaction. Here is some further information on the doxy.me payment functionality. This YouTube video really simply explains the Stripe/Doxy set up and integration.)
Your practice management system already has the ability to link video-conferencing between a patient portal and clinical staff. Get your PMS to switch this on.
There is so much 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 how you can be most helpful.
You could reduce demand by doing phone triage, manage need by seeing patients with or without a nurse in support, or free up colleague's time by dealing with inbox messages and tasks.
If you are new to virtual health, start small and review what you do regularly. Being there for your 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.
If you haven't seen the BBC interview where the US diplomat's three-year old daughter interrupts his interview - watch it now! 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 open notes to everyone in Starbucks.
You can't assume 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.
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?"
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.
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.
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.
With virtual health in your skill set you can support people doing home visits, see patients when they are overseas or start to manage multiple clinical sites.
Dr Jo Scott-Jones, Pinnacle clinical director discusses virtual care and the "new normal" following the COVID-19 pandemic.
Change is hard.
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 this different?
The rhetoric when COVID-19 emerged in December 2019 focussed on the fight against the pandemic. It was seen as a war to be fought, battles that were won and lost but eventually the hope was that we would defeat this. We would "get through".
The reality is the only infectious disease the world has managed to eradicate is smallpox.
Discussed from 1945 not completed until 1979, this relied on a determined global campaign over 13 years, an effective vaccine, case identification, contract tracing and strict quarantines.
COVID-19 is not "burning itself out" it is reaching a steady state of 3-5k cases a week, resulting in 15-20 deaths and an uncertain amount of long covid.
To put this in context 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 2-3 per cent of deaths in this country are due to lower respiratory tract infections.
Doctor's waiting rooms have long been seen as a source of infection. It is no longer acceptable to find yourself sitting in a waiting room next to someone who is coughing.
Gone are the days when people would accept the risk of sitting in the waiting room full of sick people.
COVID-19 has given us a "Semmelweis moment".
In 1847 Semmelweis recognised that handwashing reduced maternal mortality.
In 2019 we recognised that separating out the infectious patients from the non-infectious patients reduced transmission of COVID-19 and other airborne disease.
This isn't new science but 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.
Whilst wearing masks in health care settings is difficult, it is never going to be acceptable 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.
Download our virtual medicine rapid implementation plan to help you orient the team to the new way of working, get started with telephone consultations and get more comfortable with charging for virtual medicine.
New information becomes available regularly, and there is an option to subscribe to updates on the site.
We recommend the resource 'Collecting co-payments for phone or video consultations' which is part of the Virtual GP Kit. It outlines a number of approaches and systems practices can put in place to successfully bill and take co-payments before or after consultations.
Our overview of remote consultation, phone triage diary sample, clinician checklist and coding information are all great resources to get you started.
BJGPLife resource on Video consultations: A guide for practice.
Clinical triage in general practice overview with Dr Andrew Miller and the NHH Team. A clear overview of the use of the clinical triage advanced form and using clinical triage. Dr Andrew Miller shared his experience in using the forms and the benefits of clinical triage.
During the COVID-19 lockdown virtual consultations for POAC cases were funded. We are pleased to announce that this will be a permanent change.
Read moreTe Whatu Ora Waikato has noted the wording in their recent newsletter about the new BPAC disease notification eReferral, requires clarification. At this time COVID-19 remains a notifiable disease, but that notification does not need to come via GP practices using the BPAC form as it is generated via result uploading.
Read moreThis funding is available for a GP/NP consultation with patients eligible for an advance prescription for COVID-19 anti-viral medication, prior to them testing positive for COVID-19. There is no obligation for a clinician to issue an advance prescription.
View detailsThe psychosocial concerns currently experienced will be influenced by the impact of COVID-19. There will be social and financial issues - relationships strained, job losses.