Tara Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team and the Fidani Chair of Improvement and Innovation at the University of Toronto.


As the number of new cases of COVID-19 decreases in most provinces, government and professional associations are providing guidance on the reopening of clinical services to a “new normal”. Much of the specific advice is focused on restarting surgeries and procedures. There has been little guidance for family practices, typically the first point of contact in our healthcare system.

Over the last two months, family practices have dramatically changed how we deliver care. Our volumes have dropped by about 30-50% and more than 80% of the “visits” we are now doing are virtual. Many of us are assessing rashes and foot ulcers using video or photos. We are more likely to prescribe an antibiotic for a sore throat or ear without an in-person exam. Non-essential visits have been postponed including routine visits for chronic diseases or cancer screening. We are renewing blood pressure and diabetes medications without the usual office assessments, relying on home measurements when available. We are supporting an increasing number of people with mental health concerns, a challenge on the phone and video is not always possible.

Many of us are worried about the consequences of these changes in care – especially if they are prolonged. We are eager to ramp up office visits so we can start assessing more patients in-person again.

But, unlike my own practice, most family practices are not connected to a hospital and have been on their own when it comes to sourcing personal protective equipment (PPE), an ongoing challenge. And in-person visits have the potential to put patients at risk, particularly those with increased age or co-morbidities. At the same time, many assessments can be done virtually and may be more convenient for patients.

How do we balance these benefits and risks? How can we assess the impact of decisions to ramp up in-person care so we know whether we need to ramp down again?

We will need to get to a new normal for primary care practice while COVID-19 is with us for the next 1-2 years – one that balances the benefits and risks of virtual and in-person care for patients and providers.

The National Academy of Medicine’s six domains of quality offer one potential framework to systematically consider benefits and risks and get us to the new normal. We need to prevent harm to patients and staff and consider both the risks of acquiring SARS-CoV-2 itself but also the risks of deferring in-person assessments (safety). We should consider the evidence of how much an in-person intervention improves health outcomes and whether the same outcomes could be achieved virtually (effectiveness). When in-patient visits do occur, we should minimize waste of time, opportunity, and PPE (efficiency). Care should be timely no matter which mode we choose (access), meet the specific needs and values of patients (patient-centred), and enable everyone to achieve the same outcomes regardless of background (equity).

For each domain of quality, we can consider what data to collect to help us understand whether we are achieving the right balance of in-person and virtual care. Data can be collected on small samples to keep things practical and timely. Iterative cycles of planned change, data collection, and reflection can guide the process for ramping in-person care up or down or keeping things steady. The 2-part table below provides some examples of how the framework can be used by primary care practices to weigh competing issues as we strive for a new normal during COVID-19.

Our public health measures have not yet quelled COVID-19 in Canada. And it will likely be more than a year until we have an effective vaccine. In the meantime, primary care practices can use a quality improvement approach to balance benefits and risks of providing care in the office and iteratively adjust plans.

The table below (also available in PDF) provides some examples of how the framework can be used by primary care practices to weigh competing issues as we strive for a new normal during COVID-19.

Considerations for balancing in-person and virtual visits in primary care during COVID-19

Quality dimension

Considerations

Example of what data to collect

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Safety
Staff & patients
  • risk of acquiring SARS-CoV-2 and related mitigation strategies, e.g.
    1. protection from SARS-CoV-2 through adequate PPE for clinicians and staff, masks for patients, active and passive screening, and strong office infection control practices including physical distancing in the waiting room
    2. SARS-CoV-2 risk stratification and mitigation based on age and
      co-morbidities (e.g. separate office times for patients with COVID-19 symptoms)
    3. clear office policies on screening, booking, cleaning, and use of PPE
    4. risk of acquiring SARS-CoV-2 through travel to the clinic
• amount of PPE used per week; amount of PPE in stock
• calculation of the max number of patients (and staff) who can safely be accommodated in the clinic at one time
• number of staff infected with SARS-CoV-2
• number of days between incidents where a SARS-CoV-2 positive patient or staff exposes someone else in the office who is not protected
• percentage of staff who are confident in their role in booking, cleaning, and using PPE
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Safety
Patients
  • risk of virtual-only care resulting in provider-patient miscommunication or a missed or delayed diagnosis ( e_g, for a medical condition such as cancer or a social issue such as domestic violence)
  • process for staff to report patient safety incidents, including good catches
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Effectiveness
  • potential for improved mental and physical health outcomes with in-person visits. Consider evidence on the gradient of therapeutic benefit with different types of interventions from i) treatment of acute symptoms to ii) chronic disease management to iii) prevention of cardiovascular disease and cancer to iv) health promotion. Consider evidence on whether and how assessments: can be done virtually.
  • chart audit of random sample to identify reasons for in-person and virtual visits in the last week followed by team reflection to discuss trade-off in benefits and harms
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Efficiency
  • frequency of in-person visits is minimized e.g. by substituting in-person visit with a virtual visit, max-packing so multiple issues are addressed in a single in-person visit, lengthening visit intervals
  • amount of time in clinic is minimized for in-person visits e.g. by doing a virtual
    pre-visit assessment or post-visit counselling
  • PPE use is appropriate but minimized (e.g. one provider per clinic assesses symptomatic patients and these are clustered at end of day)
  • number of in-person visits per 100 patients per week
  • length of time patient spends in clinic for a random sample of encounters
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Access
  • ease with which patients can reach the office and get a timely appointment via phone, email, video, and/or in-person
  • feedback from patients and families through formal mechanisms (e.g. patient experience survey) or informal mechanisms (e.g. probe at end of visit)
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Patient-Centeredness
  • benefits of an in-person visit on the therapeutic relationship and patient-provider communication
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Equity
  • in-person care as a way to offset inequities in access to virtual care (e.g. for those with limited technological access or comfort)
  • availability of virtual options for those unable to come into the office (e.g. due to work hours, transportation, child care)
  • hart audit of random sample to understand demographics of those seen in-person vs. virtually vs. not at all
  • periodic chart review of patients with chronic conditions not seen for >12 months
Kiran T. “Ramping up in-person office visits in primary care”, CMAJ Blogs, May 2020.