Virtual Visits: The Face of Telehealth

The virtual visit is the face of the telehealth revolution. Virtual visits, also popularly known as telemedicine, are video conferences between patients and physicians or other supports.

While other telehealth practices—such as the asynchronous exchange of information and remote monitoring—have seen different levels of adoption, virtual visits have caught on the most among the masses. In the United States, the adoption of virtual visits has risen over 50% in the last 5 years. They are expected to replace around 30 million in-person visits a year in the UK.

To ensure that telehealth projects run smoothly, it’s important for directors of virtual care to:

  • Learn about the breadth of remote patient communication options
  • Map outpatient journeys for various care scenarios 
  • Identify the various virtual visit touchpoints between the patient and the care team to set up an effective care pathway

Four Types of Virtual Visits 

  Virtual visits—using remote video communication—have become synonymous with telehealth thanks to the impact they’ve made on both healthcare organizations and healthcare consumers. 

Not all virtual visits are the same. There are four types of visits, which touch all levels of care, spanning primary, urgent, intensive, and chronic care. These types are non-emergency care consultations, emergency care consultations, family connection visits, and scheduled consultations

Conducting a Virtual Visit
Virtual Visits Can be Conducted Via Stationary or Handheld Devices 

1. Non-Emergency Consultations 

Kaiser Permanente is one of the largest healthcare insurers in the USA. Over half of Kaiser Permanente’s 100 million annual visits to the doctor are now conducted online over video. These include non-emergency urgent care, as well as routine primary care and specialist care. 

Non-emergencies encompass a broad range of cases, ranging from the common cold to aches or swelling. Virtual visits with a primary physician or a specialist are currently offered under the same umbrella of virtual care services by all healthcare organizations that offer them.

Organizations do differentiate between first-time visits and established visits, and CMS has different codes in place for new patients and returning patients, respectively. It’s important to note that we are not counting e-visits and virtual check-ins as virtual visits, as both of these things can be done without live video, which is an essential component of a virtual visit. 

2. Emergency Care Consultations 

Nothing can replace dialling an emergency hotline number or visiting the emergency department (A&E in UK) in situations of immediate danger. But as a source of support at a critical moment, emergency care consultations come a close second.

These consultations are available 24/7, 365 days of the year, just like emergency rooms in hospitals. Nurses can triage patients over video to assess the appropriate level of care for them. Same-day access to physicians is possible if their expert opinion is required, and transport to the ER can be arranged. 

Physicians can even consult with stroke patients by video inside ambulances, as every second counts when making an intervention in such cases. This practice has garnered enough popularity to merit its own term, Telestroke. 

3. Family Connection Visits 

This is the only type of virtual visit that is traditionally conducted in an in-patient setting, and between patients and families, rather than patients and physicians.

In an outpatient setting, patients and their family or social circle are able to maintain normal communication with each other, as they’re going home at the end of the day. But when they’re admitted overnight to a hospital, or permanently moving into a long-term care residence, patients’ communication with the outside world may take a backseat. Moreover, as they are in the custody of clinicians and care staff, communicating with families, caregivers, and the rest of their social circle cannot be left up to the patients anymore.

This is where virtual visits come into play. Tablets like the Samsung Galaxy and iPad are being used in intensive care units (ICUs) during COVID-19 to connect those under lockdown to their families. For example, we have collaborated with our partners in the UK on the Life Lines project. Thousands of video calls thus far have been conducted at over 150 hospitals to connect families to ICU patients. 

4. Scheduled Consultations 

Scheduled consultations are associated with a sustained episode of care. They usually take place long after emergency and non-emergency consultations, when the patient is on the road to recovery.

For example, patients recovering from surgery may need a number of virtual visit follow-ups to ensure the absence of complications and a return to normal life. Using the Aetonix aTouchAway system, nurses at Joseph Brant Hospital in Toronto are able to perform two checkup calls within 24 hours of discharge. 

In other instances, a patient’s condition could be chronic and have to be managed with regular video visits scheduled over many months or years. Depending on the condition or the procedure, the need for such video consultations can be determined in advance and included as a part of the patient’s care pathway. 

Different Types of Virtual Visits

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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