"Virtual first" is a movement to provide the usual and preferred first point of contact with the health system through a virtual connection.
This 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:
"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:
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.
The World Health Organization defines primary healthcare through three key components.
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:
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.
Setting up a remote connection from home to your PMS can be difficult and is probably something you can't do yourself these days.
Use a professional - contact xcrania on 0800 XCRANIA (927 2642) or email@example.com, or your IT provider, set up a unique login and be really mindful of keeping this secure.
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 DHBs and PHOs are using Zoom "pro" accounts to host meetings and this provides an acceptable common standard, especially when hosted from an otherwise secure a computer system.
(The Clinic and Professional (paid) versions of doxy.me use Stripe as their payment gateway to process credit card transactions. Stripe charges 2.9% + $0.30 per transaction. Here is some further information on the doxy.me payment functionality. This YouTube video really simply explains the Stripe/Doxy set up and integration.)
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.
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.
If you haven't seen the BBC interview where the US diplomat's three-year old daughter interrupts his interview - watch it now! Think about your setup at home and don't let this happen!
When I first thought about virtual health I thought I would be sitting on the beach, or at a café - 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 with everyone in Starbucks.
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.
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?"
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.
Regulation and case law is going to take a while to catch up with virtual health. 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.
If you are actually sick, get well. Just because you can work from home doesn't mean you should! Read a novel, write a poem, plant a few trees, play with your kids, just rest up! Being kind to yourself is essential professional development.
Computers are great tools, but knowing when not to turn them on is a vital part of learning to use them.
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.
Change is hard.
The commonest end point of a significant pivot in the way we do things is for us to return to our original behaviour over time.
Look at every new year's resolution, every idea you bring back from a conference, even the range of medications you prescribe.
We don't like change.
We lose focus on change that must happen over time, we don't review and embed change.
We need others to help us, and we often rely on people who don't really understand what needs to happen.
We lack commitment ourselves to see change through, we fail to inspire others to commit to change.
We lose energy and find it hard to maintain the effort required to embed change.
So why is this going to be different?
It only emerged in December 2019 and New Zealand's first case was in February, just two months ago. The graphs usually show an exaggerated bell curve, with a rapid fall in cases after a peak.
The rhetoric describes this as a fight. Wars are fought, battles are won and lost but eventually we will defeat this. We will "get through".
The reality is the only infectious disease the world has managed to eradicate is smallpox.
Discussed from 1945, completed in 1979 this relied on a determined global campaign over 13 years, an effective vaccine, case identification, contract tracing and quarantine.
It is unlikely this illness will "burn itself out" as appears to have happened to SARS-Cov-1, this virus is much more infectious, and"herd immunity" (if achievable) is not a cure, it is an acceptance of prevalence.
Doctor's waiting rooms have long been seen as a source of infection.
I am certain every GP has had a patient in the past express that they don't like sitting in the waiting room because it's full of sick people.
This was usually dismissed with a shrug of the shoulders, a smile, a "What can you do, eh?"
Some of us would have apologised for keeping the patient waiting, assuming that was the underlying reason for stating of the blinking obvious.
There was an acceptance that risk was low enough, that consequences were minor, hidden or infrequent enough for us to dismiss.
We are now facing a "Semmelweis moment".
In 1847 Semmelweis recognised that handwashing reduced maternal mortality . We have recognised that separating out the infectious patients from the non-infectious patients reduces transmission of COVID-19 disease. This isn't new science.
What is new is our understanding of the need to change and we now need to act.
Semmelweis found it hard to ensure that cleaning hands between patients became the new normal, perhaps because change was imposed rather than developed through collaboration and engaging the hearts and minds of colleagues.
We are less likely to repeat that mistake because the general public will not let us.
More people across the world are contemplating routinely wearing face coverings, people are interested in the difference between aerosols and droplets, and the distance and speed at which viruses spread after a cough or a sneeze, they are asking questions about the length of time infectious particles can survive on plastic, metal, wood and paper.
It is never going to be acceptable again to sit in a place where lots of sick people have gathered and not to be provided with assurance that everything is being done to reduce transmission of disease between people.
History tells us that viruses and bacteria develop resistance to any "cure" we have created in the past, SARS-Cov2 is not going to be any different.
There may be medications that mitigate the impact of the disease, remdesivir and antiretroviral agents may interfere with viral replication, hydroxychloroquine and chloroquine may reduce the ability of the virus to enter cells, "convalescent plasma" containing antibodies generated by a person who has survived the disease may "boost" the immune system.
There is no doubt that we will develop better ways of intervening that will improve outcomes for people needing hospital care.
But it is very unlikely that we are going to be able to "cure" people of this illness with medication.
We hope when we reach "herd immunity" either through a vaccine or natural immunity of 80 per cent of the population, we will have reduced the risks to an acceptable level.
The fact is that immunity, whether vaccine induced or naturally gained, is an unknown quantity.
If this coronavirus is like the others that cause 20 per cent of common colds, immunity lasts 2-4 weeks, if it has similar properties to SARS-Cov immunity may last 2-3 years.
We don't think the virus mutates as frequently as the influenza virus, we don't know if a safe vaccine will be found, or how long-lasting a vaccine will be.
What is clear is that vaccine development is not going to be quick.
Each year in New Zealand we accept that around 10 people will die from HIV, 20 people die from TB, we may not like it, but we accept that 2-3 per cent of deaths in this country are due to lower respiratory tract infections.
COVID-19 will become another blip in the numbers eventually, and its impact on healthcare will become part of the way we do things 'round here.
People at high risk of other viral illnesses with no cure and no immunity, like Herpes and HIV, have changed behaviour to reduce the risk of catching and transmitting the virus.
This illness is going to gradually settle in the mind of the public into one of the risks that we take when we interact with others, but its global impact is not going to quickly go away in the mind of the public.
Although we rationalise the numbers of people who die each day from poverty, malaria, road traffic accidents, and medical errors the personal impact of seeing what we've seen this time feels like it will stick - the mass graves being dug in New York, the dying in hospital corridors in Italy, bodies in the street in Turkey...
The case load of SARs-Cov2 is following the same pattern of other respiratory infectious diseases.
We have seen a surge of known cases settle into a background incidence as a result of public health measures. It seems likely that this level of disease will flare and settle over time, both in the public consciousness, and in the pressure it causes on the health system.
How well we cope as a system will depend on the ability, we must keep that case load within the limits of the what the health system can cope with.
We may drift back to an acceptance of the risk when gathering to watch sports, concerts and theatre, to party and carnival, but the acceptance of risk is not going to extend to health care services.
Nor should it.
What medical students are now taught about the immune system?
COVID-19 specific information from "Ninja Nerd Science"
Global burden of disease
More scholarly reading on immune response to SARS-Cov2
For a public explanation of the current understanding of immunity and COVID-19
The advice in this forum sets out some of the general guidance on using telehealth in New Zealand at this time. Please note this is an iterative document in response to the evolving circumstances of the COVID-19 situation. They are actively working on developing additional resources for both healthcare consumers and providers, and upload new information as it becomes available.
The HCH collaborative are sharing resources to all practices as part of it's response to COVID-19.
The recent change to larger volumes of virtual care will mean practices need to change the way they collect money from people. This Virtual GP Kit guide (PDF) outlines a number of approaches and systems practices can put in place to successfully bill and take co-payments before or after consultations.
Please see our webpage: New Zealand ePrescription service - information for general practices for more details on how to get set up for ePrescribing and signature exempt prescriptions.
ACC have enabled telehealth consultations, including follow-up consultations during COVID-19. Find more information on the ACC website.