Virtual Care

Virtual care is about all the ways healthcare providers can interact with patients when separated by time or space. "Secure Clinical Communications" refers to remote communications that are asynchronous, whereas "Virtual Care" implies real-time interaction. Either can leverage one or more of text (instant messaging), audio (telephony) or video (video conferencing). "Virtual Health Services" is a broader term that includes considerations of scheduling, queuing, documenting and reporting virtual interactions.

This section relates to Virtual Care (VC) interactions between patients and caregivers.

Constraints

Patients expect communications with physicians to be private, protected and privileged. This expectation is protected by legislation, professional standards and organizational (AHS) policy. Assurance is usually provided by a Privacy Impact Assessment (PIA) specific to the communication technology and clinical context. This examines whether communication technologies are securely attached to individuals, encrypted, appropriately consented, tracked and documented.

Before any messaging, telephony or video technology is used for Virtual Care, appropriate security and privacy protections must be in place. Examples of communication technologies currently approved in Alberta Health Services (AHS) for clinical use include:

AHS is integrates Zoom technology with Connect Care. This enables e-visits, e-consults, video-visits, and other virtual services that take advantage of the enterprise scheduling, decision-supports, documentation and reporting capabilities of a full clinical information system (CIS). The AHS enterprise instance of Zoom also supports VC outside of Connect Care. It works well inside and outside of AHS networks.

Consent

While written consent is not required when using telephone or teleconferencing technology to interact with patients, patients should be informed about their options when switching from in-person to virtual care. Express consent to VC should be solicited. Patients have the right to consider the pros and cons of VC and to request an alternate form of interaction within limits set by circumstance and resources.

The outcome of informing and consenting should be documented in the record of care. The following resources include a 1-page template for informing patients about proposed changes from in-person to virtual care and SmartText that can help document consent.

Contexts

While Alberta Health Services is a leader in telehealth service, the COVID-19 pandemic poses extraordinary challenges. Many physicians are newly isolated and patients need to minimize travel. Unfortunately, telehealth suites are not well suited to social distancing.

Thankfully, professional organizations, regulatory bodies and the information and privacy commissioner acknowledge a need for flexibility in a public health emergency. Temporary use of un-regulated communications technologies, like WhatsApp and Facetime, are tolerated when they are the only available solution for an urgent clinical need.

AHS has broadened access to AHS Zoom video conferencing to avoid physician need to use unregulated communication tools.

AHS Videoconferencing

It is important to match intervention to need. Conventional telephone calls work well for many virtual patient encounters. Follow-up with text, messaging or email can also work well. Care must be taken to obtain patient agreement to virtual encounters and to document all clinically important information to the legal record of care. As much as possible, Connect Care-embedded chat, messaging and video tools should be used.

When clinical need includes virtual physician and/or patient video-presence, then AHS Zoom is the preferred VC tool. The service is available to all AHS clinicians. Use for clinician-to-clinician interaction or team meetings is easy and approved. Use for patient interaction is supported both within a CIS (integrated with Connect Care) and independent of a CIS. The clinical advantages of video-enabled VC are well established.

Basic AHS Zoom accounts are available on a self-serve basis. Advanced accounts allow scheduling of longer or more complex virtual encounters. When such additional functionality is needed by clinical areas, AHS Virtual Health (VirtualHealth.Info@ahs.ca) should be contacted. When advanced accounts are needed for training or collaborative purposes, the CMIO medical informatics program (mip@ahs.ca) can be contacted.

The following tip sheets can help AHS clinicians get started with AHS Zoom (ahs-cis.ca/zoom) for collaboration and care:

Best Practices

The COVID-19 pandemic places extraordinary demands on Internet infrastructure. Socially responsible video conference use involves minimizing bandwidth consumption. When using AHS Zoom video conferencing for clinical coordination or care:

    • Use conventional telephone interactions when adequate to the need.

    • Reduce computer screen resolutions (e.g., 1280*800 or less) when screen-sharing.

    • Do not activate video sharing by default or at the beginning of an interaction; instead, turn at the point of business or clinical need (e.g., to evaluate breathing pattern) for only as long as needed.

    • Explicitly close Virtual Care encounters when finished, freeing up the system and bandwidth for others.

    • Preferentially initiate virtual encounters from within Connect Care when the patient is a MyAHS Connect user.

    • Keep Zoom meetings as short as needed for the coordination or care task.

A number of resources are available to help physicians up-skill for use of communications technologies in service of virtual care:

Norms

Mimicking in-person communication norms may not work well for virtual interactions. Clinicians may need to learn and apply new skills that maximize the clinical effectiveness of encounters separated by time or space. The Connect Care Communication Norms offer some general precepts, while AHS Virtual Health Service offer a wealth of other tips, guides and up-skilling opportunities.

Resources