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.
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. It was boosted during COVID-19, but we think it is part of a long term solution to growing pressures on access identified by Pinnacle that led to the development of the Health Care Home model of care.
"Virtual First" approaches 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 flexibility and multiple points of access
- 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 healthcare 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 staff and people using health services are less likely to come into contact with others who are potentially infectious.
What is primary heathcare?
- Meeting people's health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritising 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.
- Empowering individuals, families, and communities to optimise their health, as advocates for policies that promote and protect health and wellbeing, as co-developers of health and social services, and as self-carers and caregivers to others.
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 could help you:
- reduce the chance of an unexpected case of an infectious disease 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 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.
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.
Tips and tricks to get started
Remote connection with the practice management system
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.
Tool up
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.
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.
Get the team involved
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.
Think privacy
Think about your setup at home and don't let this happen!
When I first thought about "virtual first" service I thought I would be sitting on the beach, or at a café seeing patients and sipping a flat white.
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 a coffee shop.
See yourself as others see you
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.
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 first approaches. 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.
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.
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.