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" (VC) 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 general principles and practices related to Virtual Care (VC) interactions between patients and caregivers. Subsections address technical and workflow considerations:
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.
Examples of communication technologies currently approved in Alberta Health Services (AHS) for clinical use include:
AHS Virtual Health Services, including conventional telehealth suites, Skype for Business, RealPresence and AHS Zoom
Before any messaging, telephony or video technology is used for VC, appropriate security and privacy protections must be in place. Patients should be screened for eligibility and technical requirements to ensure the communication technology chosen considers and supports the patient’s communication abilities.
While AHS provides a variety of healthcare-appropriate communication tools, there remain situations where no secure or approved technology is available... but asynchronous communication is essential to care. The COVID-19 pandemic poses extraordinary challenges when patients and families must be supported at a distance. Clinicians may need to use non-approved technologies that are immediately available to both provider and patient when approved tools are not.
Examples of situations where secure tools may not be usable within a clinically reasonable time frame include:
Patient portal (MyAHS Connect) activation challenges
Patient sign-up and activation for MyAHS Connect is not instantaneous. Although clinicians can issue an "activation code" with a single click, patients do not get access to the portal until they have completed registration for an Alberta.ca Account (formerly known as the MyAlberta Digital ID or MADI service). This can involve delays of a week or more. And some patients find the process complex and confusing. While Connect Care secure patient messaging is always preferred, it is not always available.
Patient and/or family email
Email communications to patients and families can be secure if sent from an AHS email account and "!Private" is inserted in the subject line. However, the email services commonly available to patients are unlikely to support equivalently secure return emails.
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 "iMessage", "GMail", or "WhatsApp", are tolerated when they are the only available solution for an urgent clinical communication need. Patients should be aware of the risks, provide verbal consent to proceed, and have that documented in Connect Care.
AHS has broadened access to secure AHS Zoom video conferencing to avoid need for unregulated communication tools for synchronous (real-time) communications. Applications like "FaceTime" should not be used instead of AHS telephony and videoconferencing.
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 VC. 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 VC and SmartText that can help document consent.
AHS 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.
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 (email@example.com) can be contacted.
The following tip sheets can help AHS clinicians get started with AHS Zoom (ahs-cis.ca/zoom) for collaboration and care:
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 VC 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 VC:
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.