Piloting Ambulatory Virtual Patient Visits During the Coronavirus Pandemic at Cleveland Clinic Lerner College of Medicine

Shreya Louis, Alexia Zagouras, Monica Yepes-Rios M.D., J. Harry Isaacson M.D., Neil Mehta M.D.

This GitHub repo is meant to serve as a source of information and provide examples from the ongoing Cleveland Clinic Lerner College of Medicine (CCLCM) virtual outpatient rotation pilot. We have been asked by a number of medical students at other institutions to share our note templates, workflow, and troubleshooting of issues so that other institutions can also help jump start their virtual outpatient rotations and education.

Since the U.S. Department of Health & Human Services Office of Civil Rights have declared a "Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency" (see more here), HIPAA rules have been relaxed to allow the use of audio and video communication technologies as long as they are not public facing (e.g. live streams are not allowed, or mediums that store videos for public viewings). This being said, health providers are still expected to take steps to ensure protected health information (PHI) is protected (e.g. turn of smart devices like Amazon Alexa and Google Home in the vicinity of tele health visits and be weary of who is within ear-shot of virtual visits to protect patient information

The main focus of our workflow is to ensure student and patient protection of private information (cellphone numbers etc), education, and usefulness to the health care team. Currently our workflow depends on EPIC, remote access to EPIC, and phone and video application access.

Workflow Steps

Click any of the below to skip to that section:

Technology Set-Up for Privacy Protection

Since most students do not have access to hospital/institution phones and will have to use their own devices, masking phone numbers will be of importance when participating in virtual visits. In a phone call from student to patient, a *67placed before the patient's number will suffice in masking the student's number. Additionally, if an attending physician calls a patient and then adds a student in by merging the calls, the student's number is automatically hidden as well. However, this becomes more complicated when a patient wants to Facetime or use WhatsApp video.

For this reason we have created step-by-step walk throughs for how to setup the various technology platforms to mask personal numbers used in this pilot found in the folder Technology Set Up or by clicking the links below:

Best for audio only:

Google Voice Set-up: Allows you to select a number with an area code of your choice to use instead your of personal number.
Basic Phone Call Masking Set-up: Allows masking with use of *67

Best for Video Calls and Audio:

FaceTime Masking Set-up: Allows for masking of caller ID to institution email instead
WhatsApp Set-up? Allows for masking of personal number using Google Voice number of your choosing

	Phone call	Google Voice	WhatsApp	Facetime
One-to-one audio
Conference call with audio >2 people
One-to-one video
Conference call video >2 people
Requires saving contacts beforehand to use
Ability to mask personal number

Acquiring Patient Consent and Protecting Protected Health Information

Patient privacy and safety is of the utmost importance. Patient permission regarding a medical student interviewing them was obtained by either appointment schedulers or preceptors. All the patients in this study gave their approval and their preference for phone (audio only) or video (FaceTime or WhatsApp) and this was recorded in the note template (required for telemedicine notes).

Students and preceptors should be aware of their surroundings at the time of virtual encounters. Smart devices such as Amazon Alexa, and Google Home that are within the vicinity of a tele health visit should be disconnected at the time of visit. Health care providers should also be aware of surroundings and determine if a re-location is necessary to carry out virtual visits in the event there is concern a third party may be able to listen in on the patient encounter.

Note Template for Virtual Encounter

See our Virtual Encounter Note Templates compatible with EPIC here.
These templates are suggestions, components may be added or deleted per physician preference.

For billing and ethical purposes, the typical in-person encounter note requirements have been ammended to include the following:

Must state encounter type phone, video etc.
Statement such as "Patient agreed to this encounter being held via ___ Yes/No
Documentation of all the people present in the encounter (e.g. any spouses, family members, as well as the student and staff physician)
Patient location during virtual visit (e.g. home, work etc.)
Time the physician spends discussing in a virtual visit needs to be recorded (typically at end of note)
Typical note components: Chief complaint, HPI, Review of Systems, Relevant labs/results, Impression and Plan, signature of student with preceptor attestation.

Virtual Physical Exam is limited, but some of the following elements have been implemented in telemedicine: \

Home Monitoring Data: Home weight on home scale, Home BP readings when applicable, home glucose monitoring, temperature if taken at home.
Phone visits: Is speech coherent, is patient able to speak in full sentences
Video visits: Rashes (one patient was diagnosed with leukocytoclastic vasculitis with this), walking the patient through maneuvers such as pressing on painful areas, pulling on ears (to check for ear infection related pain), eye movements, observing potential tremors etc.

Neurology Virtual Physical Exam

Video example of a neurology virtual exam

Link to neurology EPIC template here

General Patient Encounter Workflow

To mimic in-person outpatient rotations, we came up with two "Scenario" types for how a student could participate in clinic explained in more detail in the sections to follow along with the major PROs and CONs of each Scenario. The type of visit scenario used, will ultimately depend on a preceptor's schedule. Both students and preceptors should be prepared for the possibilty of needing to switch between scenario visit types if necessary.

Patient Assignment to Students

There are a couple ways we found to efficiently coordinate which patients a student sees.

Preceptors and schedulers can use EPIC directly to signify which patients a student should see as shown with the black dots in the image below. This is useful because students can plan visits based on the length of visit time, as well as based on the gaps between patients. Preceptors and schedulers can also add "Sticky Notes" to EPIC patient charts to signify what medium of virtual visit they prefer (e.g. phone only, or video). If the medium of choice is not available, students can just call their assigned patients close to the visit time and ask them if they prefer a video visit and transition from there.

E-mail sent to student at least a day before clinic day, telling the student which patients (using their initials) and what time the appointments are, as well as what their preferences are for virtual visits (phone vs video and what medium they would like to use).

EPIC built-in chat described below:

Preceptor and Student Communication Between and During Visits

One thing we found that is particularly useful for virtual visits in either workflow, is the use of EPIC's built-in chat. Since the chat is built within EPIC, students and preceptors can discuss patients in a secure fashion (Can also be used to send patient assignments). We found this to be very useful in coordinating when preceptors and students are both free to sync back up to discuss patient visits since you can use the chat even when a student or preceptor may be on a virtual visit on their phone. The image below shows a sample screenshot that has been deidentified of any PHI.

Visit Scenario #1: Student Sees Patient Alone First

PROs:

Students get the most learning experience from seeing patients alone and synthesizing the patients concerns in a presentation to the preceptor followed by a chance to come up with an assessment and plan by themselves.
Preceptors are able to see other patients while the student is seeing their assigned patients - can help make clinic more efficient especially as virtual outpatient visits increase in light of the COVID pandemic.

CONs:

If a patient does not pick up when a student tries to contact them, it may become necessary for the preceptor to contact the patient and transition the visit to a joint visit
If scheduling does not work out where it is appropriate for the student and preceptor to meet up to discuss the patient plan and sync back up with the patient, a Scenario type 2 visit may be more important.
Likely to be some technology issues implementing this structure in the beginning, but should hopefully be easier as visits continue.

Visit Scenario #2: Student and Staff See Patient Together