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 |
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Example of what data to collect |
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• 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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| Kiran T. “Ramping up in-person office visits in primary care”, CMAJ Blogs, May 2020. | ||
Jo
This is absolutely ridiculous! I work for a hospital and all of our staff have worked through COVID face to face…isn’t that the oath when becoming a physician?…the standard of care :”Providers will always need to prioritize office assessment of patient with new or worsening symptoms who need to be assessed in-person. Regulatory directives make clear that in-person care cannot be restricted to those who have been vaccinated or have a recent negative COVID-19 result.” Human error in misdiagnosing a patient is the number one cause of death and for family physicians to abuse their option of virtual practice is literally a direct contribution to death. Regulatory bodies/Ministry of health need to enforce the same punishments as they do in all work sections; lay persons example: imagine talking to your mechanic over the phone or online about the troubles your having with your vehicle. A mechanic needs to see the car to fix the problem, as do doctors. The price to pay for a life is much higher and therefore needs to be taken seriously. I know of a dear 4 year old little boy whom was denied face to face consults with 3 pediatricians whom all virtually guessed that his 3 week lasting cough will just go away without an anti-biotic prescription or further diagnostic testing. Presence of a fever was there (fever monitors used by parents in the ear are 5 degrees off therefore a trained professional needs to physically assess with true diagnostic instruments to see if a fever is present)….this was missed…and listening to the pneumonia lung crackles is missed virtually, thus placing a child’s life in danger of dying from undiagnosed pneumonia because the doctor was scared of covid-19. The child also had 2 covid tests performed and both resulted in a negative covid result, yet the child is still refused in patient care by the pediatric doctors. What are we doing here? do moral or ethical tests need to be done on these physicians or audits on their high OHIP billing outcomes from numerous daily virtual calls be investigated? I ask at what price will it cost for physicians to understand that in person visits are necessary for proper/life saving health care? Why don’t we just have fire fighters fight fires over the computer instead of in person!
Mehran Mogharrabi
Very good
Luis Rivero Pinelo
Very real situation changing probably forever our clinical care. Very good discussion about conflictive conditions need ramp up consults or referral to closest ER
Kimberly WIntemute
Thanks for this helpful construct, Tara. A really thoughtful and useful evaluation.
Carol Herbert
While virtual care is clearly preferable for some conditions and some patients, there are limitations. One of my relatives fell at the beach on an early morning walk, and injured her back. She – and I by long distance phone- thought it was likely soft tissue injury. When she didn’t improve, she consulted her family doctor by phone and then her rheumatologist by phone. It took 17 days before the continuing pain and associated symptoms resulted in an emergency room visit where sacral and bilateral ischio-pubic pelvic fractures were diagnosed. Physical exam would have detected this serious condition. Telephone medicine risks confirmation bias – diagnostic assumptions that do not require face to face assessment and the associated issues during the pandemic may be more likely.
Paul Gill
We have developed a guide in SW Ontario re: re opening of primary care and specialist office practice.
It can be found here
https://swcovidtools.ca/guide-to-re-opening-your-office/
Hopeful it can at least help folks organize their thoughts and help strategize their reopen plans and priorities.
Paul
Frank Gavin
I’m glad to see feedback from patients and families included among the data to be collected. We should think carefully about which patient experience surveys to use and what should be changed in or added to these surveys in this new environment. The “waiting experience,” for instance, is now more varied and in many instances quite different from such experiences in the past.
In the last several weeks I’ve heard and read quite a bit about how much patients like virtual care, often preferring it to office visits. I worry this–“patients prefer virtual care”-will become a truism. Which patients? In what situations? For what reasons? I’m lucky to have had the same primary care doctor for the last 35 years. Even when we use just the phone, we can, to a large degree, “see” one another. When you know someone, tone can convey a great deal. I wonder, though, about situations where a primary care provider and a patient have had little if any prior contact and no real relationship. Maybe virtual care can work just fine in such a context, but deciding or accepting that something is “the new normal” can obscure its limitations.
Tara Kiran
I completely agree, Frank. At UofT, we’ve modified our patient experience survey to be COVID relevant — asking about access , patient-centredness, and also patient’s experience with virtual care modes (email, phone, video). We’ll be launching the survey this month and are happy to share with others who want to use it.