Spring 2022 (Volume 32, Number 1)

Optimizing Virtual Care During the COVID-19 Pandemic and Beyond

By Sahil Koppikar, MD, FRCPC; and Brent Ohata, MD, CM, FRCPC

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With the resurgence of the COVID-19 omicron variant, we have been forced again to attend the CRA Annual Scientific Meeting online in our living rooms, and many of us have transitioned back to seeing patients virtually. After two years, an end to the pandemic remains elusive. It is therefore increasingly likely that our current practice patterns — a blend of in-person and virtual encounters — will become the “new normal.” As our practice patterns evolve, it is incumbent on us as a community to develop strategies to deliver the best possible care virtually. Below are several tips to improve the care you deliver virtually:

1. Book video appointments instead of telephone appointments.
Video appointments not only allow for a modified physical exam, but they also facilitate interpersonal interactions. For patients who struggle with technology, successful video appointments can still occur with the assistance of family/friends, in local health clinics when home internet speeds are slow, and after test runs with your staff.

2. Develop strategies with your administrative staff to improve the virtual care connection and environment.
An optimized virtual environment facilitates better clinical care. Struggling with poor connectivity, poor audio/ video quality, and inappropriate appointment locations waste time and detract from clinical data quality. Actions taken by your staff to improve the likelihood of a successful appointment will reduce your stress. Helpful strategies include:

1. Appointment reminders that include preferred devices and web browsers, suggestions for improving internet speed, ideal locations and clothing, and lighting tips.
2. Collecting telehealth consent forms and patient-reported outcome measures prior to the visit.
3. Having patient sign in 15 minutes prior to the appointment, so administrative staff can troubleshoot any technical challenges before you enter the virtual encounter.
4. Entering pharmacy, lab and imaging department fax numbers into the electronic medical record prior to the visit.

3. Become more comfortable and creative conducting a physical examination over video appointments.
Although many virtual physical exam maneuvers are not validated yet, they still provide invaluable information that impacts clinical decisions. These techniques have often been developed by health care providers who are comfortable with virtual care in various populations. Several good resources are available, including Bone and Joint Canada,¹ the Mayo Clinic,^2,3 and from evidence-based practical frameworks for the MSK exam.⁴ The CRA has also developed accredited interactive modules to help with rheumatological virtual visits and physical exams, to be released this spring.

4. Virtual care is ideal when integrated within a holistic model of care (MOC).
As rheumatologists, we still rely heavily on in-person assessments, especially if the virtual examination does not allow for decision-making. Virtual care should be viewed as a complement to, not a substitute for, inperson care. Virtual care may improve access to and continuity of specialist care, especially for patients with sporadic access to rheumatology. It allows for collaboration with extended-role practitioners (i.e. Advanced Clinician Practitioners in Arthritis Care [ACPACs]) in underserviced areas to enhance care and outcomes. Creative models utilize virtual care in between appointments to support patients in various ways, including self-monitoring applications, educational courses, biologic injection classes, and rapid access “hotlines.” With creativity and innovation, we can leverage virtual care moving forward to provide better care to our patients within a comprehensive and inter-disciplinary MOC.

Sahil Koppikar, MD, FRCPC
Assistant Professor, University of Toronto
Women’s College Hospital,
Toronto, Ontario

Brent Ohata, MD, CM, FRCPC
Clinical Assistant Professor, UBC Division of Rheumatology
Burnaby, British Columbia

References:

1. Bone and Joint Canada. “Virtual Assessment of Musculoskeletal Conditions: How to Set Up a Program to Meet the Needs of Patients, v.1, March 10, 2021. Available at boneandjointcanada.com/virtual-care/. Accessed February 10, 2022.

2. Laskowski ER, et al. The telemedicine musculoskeletal examination. Mayo Clinic Proceedings. 2020; 95:1715.

3. Wainberg MC, et al. The telemedicine hand examination. Am J Phys Med Rehabil. 2020; 99:883.

4. Murray, T, et al. Remote Musculoskeletal Assessment Framework: A Guide for Primary Care. Cureus. 2021; 13(1);e12778.