Telehealth / Virtual care for new users
I have been doing telehealth / virtual care for a Wollaston Lake (a remote nursing station in Northern Saskatchewan) for the past 2 years now. I have been doing a weekly clinic with the assistance of the nurses at the nursing station who help with preparing patients, doing the physical examination for me and ensuring that visits go smoothly. Then about once a month I would go to the community for a few days to provide in person face to face clinics. Through this experience, in discussions with others and advice from other sources I have compiled a list of helpful suggestions to make virtual care / telehealth provide the best clinical care you can given its limitations. This is certainly not an exhaustive list of suggestions and I am happy to take feedback to improve these suggestions.
In a virtual care model your presence and background portrays your professionalism and affects how the patient views the interaction. Things to be aware of:
1. I usually try to use 2 computers with their monitors stacked one on top of the other so that when I am looking at the EMR computer screen I am also looking at the web cam and directly at the patient rather than looking away.
2. Set up your webcam at eye level
3. Restart your computer prior to initiating a telehealth / virtual care visit. This limits other software that might be otherwise using resources in the background
4. Use a newer computer if possible as they have more computing power to manage the demands of the video processing. If you are having difficulties, reducing the resolution can help by reducing bandwidth and computer power requirements.
5. Use a hard wired, fast internet connection instead of wireless, this will provide a stronger and better connection.
6. Use headphones if you need to. I use headphones when using peripherals such as a blue tooth stethoscope on the patient end (not all virtual care platforms have this ability).
7. Be aware of background, I often use a green screen, but certainly be aware of what is behind you
8. Lighting – set up a light in front of you or change the angles of your screen (s) so that you are not casted in a shadow.
9. I am not a fashionista and I am colour blind, so this advice is shamelessly taken from others. Excessively bright or dark colors should be avoided, and white shirts / coat can washout your face. Pinstripes, checks, and other ‘noisy’ patterns can be jarring on the screen.
1. Be aware of other people in the room, identify who they are (including off camera).
2. Be aware of open doors / windows that could allow for possible breaches of privacy.
Using telehealth / virtual care is a still a novel way of creating a physician patient interaction, so in my opinion being aware of and intentionally establishing rapport is arguably more important to ensure concordance with patients. Personally, I use humour as much as possible. For example, when asking about smoking if they answer that they smoke, I then ask when they are going to quit…. And wait for a response. They usually have not been asked in this way and it injects a bit of humour. They either say they never will quit (and I thank them for their honesty) or that they’ve been thinking about it or working on it, which then segues into a smoking cessation intervention.
Remember that even when you’re not talking, you can still be seen onscreen, and your behavior affects how the patient feels. If you need to look away, tell the patient what you are doing and why, otherwise it can come across as being distracted, unresponsive or disinterested. For example, I will often tell patient’s that I am typing up a referral letter and then read it to them to ensure I have it accurate.
While you’re talking, maintain eye contact with your patient by looking straight into the webcam rather than at their face onscreen. Also, nodding as they speak and asking the right questions keeps patients engaged. This can move things along and make your patient feel heard and appreciated.
Remember from your early medical school days that your examination begins with the “end of the bed o’gram” or general inspection. Is the patient well / unwell.
Vitals:
Resp rate can be observed and counted
Pulse rate can use a device if they have one or teach them to take their own pulse
02 saturation – Roth score (Chorin et al., 2016) deep breath then count 1-30 in 1st language
a. <#10 or <7s to breath then sat <95% with sensitivity of 91% and specificity of 83%
b. <#7 or<5 s to breath then sat <90% with sensitivity of 87% and specificity of 82%
Abdo exam or other examinations can be done using another person as an assistant.
Explain how to do the examination, what you are looking for and why
References
Chorin, E., Padegimas, A., Havakuk, O., Birati, E. Y., Shacham, Y., Milman, A., Topaz, G., Flint, N., Keren, G., & Rogowski, O. (2016). Assessment of Respiratory Distress by the Roth Score. Clinical Cardiology, 39(11), 636–639. https://doi.org/10.1002/clc.22586
