Lim, Rodrick

Rosenfield, Daniel

Tse, Sandy

English

Scholarship@Western

Western University Scholarship@Western Paediatrics Publications Paediatrics Department 1-1-2021 Implementing virtual care in the emergency department: building on the pediatric experience during COVID-19 Daniel Rosenfield Hospital for Sick Children University of Toronto Rodrick Lim Western University, rod.lim@lhsc.on.ca Sandy Tse Children's Hospital of Eastern Ontario, Ottawa Follow this and additional works at: https://ir.lib.uwo.ca/paedpub Citation of this paper: Rosenfield, Daniel; Lim, Rodrick; and Tse, Sandy, "Implementing virtual care in the emergency department: building on the pediatric experience during COVID-19" (2021). Paediatrics Publications. 2049. https://ir.lib.uwo.ca/paedpub/2049 Vol.:(0123456789)Canadian Journal of Emergency Medicine (2021) 23:15–18 https://doi.org/10.1007/s43678-020-00026-21 3EDITORIALImplementing virtual care in the emergency department: building on the pediatric experience during COVID‑19Daniel Rosenfield1 · Rodrick Lim2 · Sandy Tse3Received: 8 July 2020 / Accepted: 25 August 2020 © Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d’Urgence (ACMU) 2020Keywords Emergency medicine · Pediatrics · Medical informaticsBackgroundVirtual care has been defined as any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or informa-tion technologies with the aim of facilitating or maximizing the quality and effectiveness of patient care [1]. The World Health Organization has advocated for virtual care to solve issues of increased demand for timely healthcare access and shortage of health care professionals [2]Canadian emergency departments (EDs) suffer from sys-temic issues and significant resource constraints [3]. Barriers to adoption of virtual care in Emergency Medicine (EM) prior to COVID-19 include governance of compensation, licensure restrictions, and lack of connectivity to resources required to build the system [4]. Already faced with signifi-cant challenges to in-person care in the ED, virtual solutions were not prioritized despite 44% of health care consumers indicate a willingness to access virtual options [5].Since the start of the pandemic, virtual care in Canada has exploded in its usage, scope and ubiquity. Clinicians have adopted video technology in primary care, hospital wards and community mental health units while patients/families accepted a new interface. In Ontario, some ED groups use virtual care to assess patients in long-term care, decreasing transfers. Other EDs adopted virtual follow-up on discharged patients or virtual psychiatry consults for mental health assessments. The pediatric emergency department (PED) is no exception, with variable virtual offerings. The Chil-dren’s Hospital of Eastern Ontario (CHEO) began booking ED virtual same/next day appointments for families at home seeking medical care for their children [7]. London Health Sciences Center (LHSC) opened an after-hours virtual “ED waiting room” nested in their departmental electronic medi-cal platform. SickKids in Toronto rolled out virtual subspe-cialty consults for children physically located in the ED.Many hospitals across Canada are now working to establish and improve virtual offerings, creating a unique opportunity to standardize, harmonize and optimize virtual care. Based on our experience to date, we offer insights into developing ED virtual care; and while our patient popula-tion is pediatrics, the many of the lessons learned can be applied to general EDs and outpatient urgent care/primary care settings.PrinciplesVirtual emergency medicine care is uniquely patient driven, and must coordinate the right patient to be seen at the right time by the right provider using the right technology (Table 1). Effective EM care must understand the needs of the community it serves and apply a virtual strategy that can be optimized to that environment.Several regulatory resources have been published set-ting out guidelines for medical professionals to implement virtual care [9]. These guidelines establish clear protocols for identifying the physician and patient, disclose the legal and regulatory responsibilities of the physician, and identify Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s4367 8-020-00026 -2) contains supplementary material, which is available to authorized users. * Daniel Rosenfield  Daniel.rosenfield@sickkids.ca1 The Hospital for Sick Children, University of Toronto, 525 University Avenue, 12th Floor, Toronto, ON M5G 2L3, Canada2 London Health Sciences Center, Western University, London, ON, Canada3 Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, ON, Canada16 Canadian Journal of Emergency Medicine (2021) 23:15–18Vol.:(0123456789)1 3recourse for the patient to follow-up if further instructions are required or if their health worsens [9, 10].Right patientIn a climate of fear for COVID exposure and concern for delay in seeking medical attention [8], CHEO and LHSC adopted virtual care to provide families and children an alternate route to direct timely access from an established trusted source. Diverting low acuity problems to a virtual model maintains social distancing and decreases potential exposures in the ED.Consideration for the target population is crucial to best inform strategy, operations, logistics and communication. In pediatrics, there are many subpopulations that will almost always require in-person assessments (Appendix Table 1), and thus any virtual care strategy should direct them appro-priately. For this, communication strategies are key to ensure successful implementation and minimize community disap-pointment or physician concern.The legal implications are important to discuss and plan for within a practice group. Limitations of virtual care must be clearly communicated and pathways for patients to receive in-person care, where appropriate and available, are necessary [11]. Practically, this means that if a patient seen virtually provides a history that necessitates a physical examination that cannot be executed remotely, the patient should be redirected [12].Barriers exist for families with limited English or French to access virtual care. Equally evident is the socioeconomic or age barriers that may exist. Strategies to have translation available, options for access to technology and care supports are key to ensuring equity.Right timeVirtual care allows families to access care from home, eliminating travel time and ED wait times. Previous surveys of families presenting with low acuity problems suggests that many have primary care providers but did not access them first or could not get a timely appointment [6]. Open 24/7, PEDs have faced long wait times due to this influx of patients. The idea to utilize virtual care to keep low acuity visits away from ED waiting rooms has potential to prevent overcrowding and cut down on PPE use. Additionally, EDs could use virtual care to minimize return assessments. To optimize implementation, EDs need to understand their daily case load, times of peak volume, how best to schedule medi-cal staff, and create a virtual model that both supports the existing structure and fills the gaps.Right providerIt is essential that virtual ED work collaboratively with primary care providers, to offer services that are comple-mentary and results in better coordinated and timely service delivery.Emergency physicians are a scarce commodity and must be used effectively. During a pandemic, virtual care shifts are ideal for ‘at risk’ staff. After the pandemic, there may be residual benefits, including allowing staff with health or age limitations to contribute to ED work in a more flexible model of care.Clinicians working in the ED are funded in various ways; from fee-for-service to salaried to alternative funding plans. Equitable arrangements must be sought to balance working ED and virtual shifts, and payments should neither penalize nor reward any new model of care implemented on a virtual platform. Seeking clarity around funding opportunities from provincial authorities is necessary to ensure longevity of any virtual service.Right technologyHardware, software and information technology resources are significant considerations when implementing a vir-tual platform. At its most basic, a simple telephone call regarding outstanding laboratory or imaging results or Table 1  Summary tableDeterminant of success ExampleRight patient Delay seeking care due to fear of infectious disease (eg COVID) or doctor’s officeNo requirement for labwork or other investigationsRight time After-hours care for low acuity complaintsFills gaps in service for your communityRight provider Knowledge or expertise from emergency specialistIntegrated with existing care by other medical providersRight technology Videoconference—Compliant to regulations, ensures privacy, barriers removed to ensure equity17Canadian Journal of Emergency Medicine (2021) 23:15–18 Vol.:(0123456789)1 3following-up for a brief assessment to find out how a child is doing after discharge qualifies. More commonly, virtual care brings to mind a video-conferencing system. Hard-ware required for the clinician includes a computer with a high-resolution webcam, microphone, along with a pri-vate space to conduct assessments. On the patient’s side, a smartphone, tablet or laptop with built-in webcam can be utilized. Internet capacity should be optimized (high speed) for best connectivity.The software must be compliant with provincial privacy and security legislation (eg. PHIPA in Ontario). Ease of use, for both the clinician and family is important. Some examples of current software include Ontario Telehealth Network (OTN), WebEx (Cisco)™ and Zoom for Health-care™. Optimally, an integrated electronic medical record (EMR) would allow for timely documentation of the vir-tual assessment and for patient chart visibility across mul-tiple providers to ensure appropriate (and nonrepetitive) continuity of care.Logistics for easy web-access, registration processes, and development of standardized information for the patients to self-download is important. Training materials for physi-cians should be developed and a process for iterative change/improvement in place to ensure smooth operation. Follow-up surveys or other mechanisms for feedback from users and providers are useful to ensure that fixable issues are addressed.Consideration to barriers to access should be studied carefully as some technology requirements may prohibit those with disabilities or lower socio-economic situations from successful access.Future considerationsVirtual care can be utilized to improve health equity for numerous populations within Canada who have poor access to care due to geographic considerations, marginalization, or other factors. While there are significant barriers to attaining this goal (i.e. improving infrastructure to provide high-speed internet across rural settings), with proof of concept already achieved and more widespread acceptance gained, hospitals and EDs can help advocate for these projects to improve patient care in these communities.Many EDs and PEDs act as referral centers and resources to their communities. Virtual care can help improve existing partnerships and help forge new ones. Leveraging virtual care platforms from within the ED to help facilitate care for high acuity cases, or potentially defer travel requirements for those who do not need to be transferred, may have signifi-cant benefits for patients and cost savings to the healthcare system.ConclusionVirtual care in the pediatric emergency department is still in its infancy but is growing and innovating at a signifi-cant speed. As virtual offerings become a new standard, guiding principles will help to build the most robust and appropriate care model required for each community. The principle of “the right patient to be seen at the right time by the right provider and using the right technology” com-municates the idea of maintaining close links with patient populations, advocates to build systems and remove bar-riers, and connecting with community health providers. These are unprecedented times during COVID-19, allow-ing us to shape care models for years to come. The oppor-tunity should not be squandered.Compliance with ethical standards Conflict of interest The authors declare no conflict of interest.References 1. Shaw J, Jamieson T, Agarwal P, et al. Virtual care policy rec-ommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique. J TelemedTelecare. 2018;24(9):608–15.  2. World Health Organization. Draft Global Strategy on Digital Health 2020–2024. Available at: https ://www.who.int/docs/defau lt-sourc e/docum ents/gs4dh daa2a 9f352 b0445 bafbc 79ca7 99dce 4d.pdf?sfvrs n=f112e de5_3 Accessed March 2020 3. Affleck A, Park P, Drummond A, Rowe B, Ovens H. Emergency Department Overcrowding and Access Block. CJEM. 2013; 15(6):359–370. Available at: https ://caep.ca/wp-conte nt/uploa ds/2016/03/cjem_2013_overc rowdi ng_and_acces s_block .pdf 4. Canadian Medical Association. Virtual Care in Canada: Dis-cussion Paper. 2020. Available at: https ://www.cma.ca/sites /defau lt/files /pdf/News/Virtu al_Care_discu ssion paper _v2EN.pdf Accessed July 4 2020 5. Ipsos Global Advisor. Global views on healthcare - 2018. Available: www.ipsos .com/sites /defau lt/fles/ct/news/docum ents/2018-07/globa l_views _on_healt hcare _2018_-_graph ic_repor t_0.pdf. Accessed June 2020 6. Farion K, Wright M, Zemek R, Neto G, Karwowska A, Tse S, Reid S, Jabbour M, Poirier S, Moreau K, Barrowman N. Understanding low acuity visits to the pediatric ED. PLoS ONE. 2015;10(6):e0128927.  7. Reid S, Bhatt M, Zemek R, Tse S. Virtual care in the pediatric emergency department: A new way of doing business? CJEM. 2020. https ://doi.org/10.1007/s4367 8-020-00048 -w. 8. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy result-ing from fear of COVID-19. Lancet Child Adolesc Health. 2020;4(5):e10–1.  9. https ://www.cpso.on.ca/Physi cians /Polic ies-Guida nce/Polic ies/Telem edici ne Accessed July 30, 2020 10. Canadian Medical Association. Virtual Care. Recommendations for Scaling Up Virtual Medical Services. Available at: https ://18 Canadian Journal of Emergency Medicine (2021) 23:15–18Vol.:(0123456789)1 3www.cma.ca/sites /defau lt/files /pdf/virtu al-care/Repor tofth eVirt ualCa reTas kForc e.pdf Accessed July 30, 2020 11. Canadian Medical Protective Association. Providing virtual care during the COVID-19 pandemic. https ://www.cmpa-acpm.ca/en/advic e-publi catio ns/brows e-artic les/2020/provi ding-virtu al-care-durin g-the-covid -19-pande mic Accessed August 2nd, 2020 12. Canadian Medical Association. Virtual Care Playbook. Available at: https ://www.cma.ca/sites /defau lt/files /pdf/Virtu al-Care-Playb ook_mar20 20_E.pdf. Accessed August 2nd, 2020Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Implementing virtual care in the emergency department: building on the pediatric experience during COVID-19

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Implementing virtual care in the emergency department: building on the pediatric experience during COVID-19

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