cv transistion to virtual care
Marcie Hopkins, U of U Health.
improvement
How Utah’s Cardiovascular Center Made (and Sustains) the Transition to Virtual Care
Director Lora Stratton details how Utah’s Cardiovascular Center leveraged team creativity and rapid problem solving to make—and sustain—the shift to virtual care. Cardiologist Anu Abraham shares what it looks like in practice.
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hen the pandemic began, we had to call most of our patients to cancel their appointments because we weren’t set up to see patients virtually. At the time, we didn’t have access to MyChart (Epic’s platform for virtual care), so we had to schedule appointments using Zoom or InTouch. Just like a meeting, Zoom required us to send an email to every patient with an invitation to join the Zoom call. We quickly realized that we needed a clear, manageable process to better serve our patients. 

By relying on our team—Clinical Nurse Coordinator Angie McGuire and our medical assistants—we have transformed into an organized virtual and in-person clinic. Here’s how:

1. Make it easier for patients by anticipating which platform to use

MyChart is now our preferred method of virtual visits, but it’s not a one-size fits all and doesn’t accommodate all patient needs. For example, we use other virtual care platforms, like Zoom and Doximity, for patients living in care centers with non-family support. So to help the patient plan for their appointment, we have to know which platform the provider will use. 

Help patients know what to expect before the appointment. We reach out to patients 24-48 hours in advance of their appointment. We let them know which web platform to expect, and also to “pre-room”—go over the patient’s meds, history, pharmacy, level of pain, all of the same information that would happen if the patient came in person. Importantly, we set the expectation with the patient of which platform (MyChart, Zoom, Doximity, etc.) they’ll use.

Personalize your confirmation. We send patients an email from University of Utah Health Cardiology (instead of our personal emails) with the Zoom instructions and all of the consent forms. We created our own email because we wanted to be mindful that our patients (and all of us) receive a lot of spam. The patient knows we are deliberately communicating with them by using their name, appointment time, date, provider and the Zoom link. If the patient replies, an auto-reply tells the patient how to get in touch with us.

 

Dear <Name>, 

Your virtual visit appointment has been scheduled and the details are below:

          Appointment Date: XXX
          Appointment Time: XXX
          Provider: XXX

To begin your visit, click this link: <Insert Zoom Link Here>

To ensure you have a good visit, please keep these tips in mind.

  • During the visit, limit the number of devices utilizing the internet in your home. Turning off video game systems, video streaming, and music streaming will help increase signal quality.

  • Please log into your visit 5 minutes prior to your appointment to complete any necessary questionnaires, and to test your connection.

  • If this is your first visit, you may be asked to download an app to support the appointment on your device. To view a one-minute tutorial on how to join a Zoom video conference, click here

  • At your scheduled appointment time, please use the link above to begin your visit.

You may be asked to verbally agree to our University consent forms during your visit. Please see these hyperlinks to review these materials.

Conditional Agreement

Notice of Privacy Practices (English) (Espanol)

If you have any questions regarding your appointment, please call the Cardiovascular Center at (801)-585-7676 or send a MyChart message to your care provider. We look forward to seeing you for your appointment!

Sincerely,

The Cardiovascular Center Providers and Staff

2. Establish clear expectations for clinic support roles

When we first started virtual care, we thought, "Oh, it's all virtual, so the providers won’t need much, they’ll just get on and connect.” We soon discovered that is not true. Providers cannot run a virtual clinic without support. We do a lot of work to get patients connected, which has completely changed how we staff our clinic. We have two staff members assigned to each physician care team every day. One person calls the schedule for the day or two in advance (pre-calling), and one person runs the virtual clinic (point). We’ve created clear expectations around each role. 

  • Transition appointment. Use platforms according to provider preference/capability. 
  • Call all in-person visits for the CVC to remind them that they will still be seen in the clinic. (Appointment reminders are off for now.) 
  • Complete rooming process. This is a full rooming, just like the patient would be in person.
  • Schedule appointment in platform (InTouch/Zoom*) or change the appointment to MyChart visit in Epic.  
    • No InTouch access: reach out to a pod lead to schedule. Use UUH Cardiology waiting room regardless of location.
    • *Currently only Lora/Angie are scheduling in Zoom.
  • Update appointment notes with the virtual visit platform and also indicate patient was roomed.     
    • Please note which device the patient has (Android or Apple).
  • In-person visits are at the provider's discretion. 
  • If unable to reach patient, create a telephone encounter with reason for call and your extension. Be specific in encounter.
  • Monitor for add-ons and complete the above steps. 

These are general responsibilities. Some of the above duties will vary per pod.

  • Contact provider via Skype or Smartweb to let them know you are running point for the day. Provide your extension.
  • Run clinic for the assigned provider for the day. 
  • Watch for add-on patients.
  • Complete rooming/transitions that have not been completed from prior day.
  • Do follow-up encounters (may have to review prior days for note completion for tasks).
  • Assist with patient connectivity (watch schedule for successful patient login to specific platform).
  • No Shows: if patient has been roomed but no-shows on the day of appointment, enter "Erroneous Encounter" in chief complaint.

These are general responsibilities. Some of the above duties will vary per pod.

  • Place orders for the PDA's. 
  • Take calls from other teams’ patients that called back to be roomed.
  • Mark the previous days no-show appointments with "Erroneous Encounter" in chief complaint for all CVC providers/teams.

One of the main responsibilities of the point person is to assist with connectivity. If the point person notices the patient hasn’t connected within 10 minutes of the appointment time, they call that patient to ask, "Hey, I don't see you logged in for your visit yet. Did you get the link? Are you doing okay?” 

If that provider is also seeing in-person visits, they will take care of the in-person visits at the same time. We have specific follow-up processes for after the patient has been seen to ensure we have followed up on any additional testing or checked in with the patient if we have adjusted any medications or plans of care.

3. Leverage the team’s expertise

This virtual care journey has reminded me not to underestimate the creativity and problem-solving ability of your team. We all want to do a good job.

All of our processes were created jointly, by experimenting and huddling together. In our team huddles we talk about what works and what doesn’t. For example, one of our at-home employees identified the need for the orders role after noticing that we struggled to connect with patients on subsequent tries if we didn’t connect on the first try. The “orders” person answers the phone directly when the patient calls back and finishes rooming the patient. 

Another staff-driven improvement has been to clearly identify roles. At the beginning, whoever was in on that day called patients. We didn’t assign people to particular providers. The result was a lot of frustration, especially as some work was incomplete or done incorrectly. Now, the same individual running clinic makes their own calls in advance. They know what to expect because they set it up themselves.

The physician’s perspective

Dr. Anu Abraham

Lora asked Anu Abraham, a general and interventional cardiologist, how she has adjusted her practice to virtual care.

“I’m much more efficient. I find that I spend more time with the patient instead of waiting for the patient to be roomed. In my in-person clinic, I have an APC (Advanced Practice Clinician) that sees the patient before me. Now, my APC and I work together differently.

I see the patients first. I can type while I talk, which means I can get my orders in more quickly. I introduce the APC so the patient knows who they are and that they help care for the patient. They will answer messages, follow up, and connect with me. 

Virtual care is more convenient and efficient for my patients. I can spend the full time talking with them. At first, I was worried because most of my patients are over 60. But I’ve been surprised—for the most part, they have smartphones. They can connect. They’re thrilled to see me virtually from places like Elko, Nevada.

I have set up my office in the School of Medicine to do virtual care. I set up my monitor and my keyboard so I’m not looking away from the patient. I work from my office because there are fewer distractions than in our clinic space. While I miss chatting with my colleagues in clinic, I notice that it takes me longer to chart or message when I’m constantly getting interrupted. When I see patients in my office, I’m much more efficient and I run on time.”

Contributors

Anu Abraham

Assistant Professor (Clinical), Cardiovascular Medicine, University of Utah Health

Lora Stratton

Director, Cardiovascular Care, University of Utah Health

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