Professor Trisha Greenalgh at the University of Oxford, along
with input from Clare Morrison of the Scottish Government’s technology enabled
care programme and Professor Gerald Koh Choon Huat from the National University
of Singapore lay out some tips.
This guide covers the following questions:
1. When are video consultations appropriate in primary care?
2. How can a GP practice get set up for video consultations?
3. How can a clinician conduct a high-quality video consultation in
primary care?
4. How should patients prepare for, and participate in, video
consultations?
It also includes a preliminary template for a video consultation in
primary care with a patient who may have Covid (further below.)
1. When are video consultations appropriate in
primary care?
Covid-related
consultations: video may be appropriate when
- The
clinician is self-isolating (or to protect the clinical workforce)
- The
patient is a known COVID case or is self-isolating (e.g. a contact of a known
case)
- The
patient has symptoms that could be due to COVID
- The
patient is well but anxious and requires additional reassurance
- The
patient is in a care home with staff on hand to support a video consultation
- There
is a need for remote support to meet increased demand in a particular locality
(e.g. during a local outbreak when staff are off sick)
Non-Covid-related consultations: video may be appropriate for
- Routine
chronic disease check-ups, especially if the patient is stable and has
monitoring devices at home
- Administrative
reasons e.g. re-issuing sick notes, repeat medication
- Counselling
and similar services
- Duty
doctor/nurse triage when a telephone call is insufficient
- Any
condition in which the trade-off between attending in person and staying at
home favours the latter (e.g. in some frail older patients with multi-morbidity
or in terminally ill patients, the advantages of video may outweigh its
limitations)
On the basis of current evidence, we suggest that video should not generally
be used for:
- Assessing
patients with potentially serious, high-risk conditions likely to need a
physical examination (including high-risk groups for poor outcomes from COVID
who are unwell)
- When an
internal examination (e.g. gynaecological) cannot be deferred
- Co-morbidities
affecting the patient’s ability to use the technology (e.g. confusion), or
serious anxieties about the technology (unless relatives are on hand to help)
- Some
deaf and hard-of-hearing patients may find video difficult, but if they can
lip-read and/or use the chat function, video may be better than
telephone
2. How can a GP practice get set up for video
consultations?
Decide and plan
- Practice
meeting (perhaps virtually)
- Involve
practice manager, clinicians, administrative staff
- Agree
what kind of appointments will be done by video
- Agree
what hardware and software will be used
- Ensure
staff know about the plans and their concerns are heard
- Develop
links with local technical support team
Set up the technology
- Internet
connection (preferably, fast broadband)
- Technology
in place (select and install video call software and peripherals such as
webcam, microphone)
- Hardware
and software up to date and audio/video working
- If
working remotely, ensure home technology meets standard and there is read/write
access to the practice’s clinical record system
- Produce
information for patients on what technology they need
Set up the workflows
- Update
practice website with information on video calls
- Update
clinic templates to show availability for video calls
- Create
appointment code for a video consultation
- Put
process in place for scheduled & unscheduled appointments
- Put
arrangements in place for in-person contact (e.g. collection of forms); ensure
prescriptions are sent directly to pharmacy
- Make
contingency plans for what to do if video link fails e.g. clinician will
contact patient by phone
Training and piloting
- All
staff have been trained in the new system and are competent
- Clinicians
have all the necessary equipment in their rooms (or access to a shared room)
- Technical
aspects have been tested by making a dummy call
- Staff
have tested the process (including making an entry on patient’s record,
arranging follow-up, sending prescription etc)
- A
patient / layperson has tested the process
3. How can a clinician conduct a high-quality video
consultation in primary care?
Before the consultation
- Confirm
that (as far as you can assess in advance) a video consultation is clinically
appropriate for this patient at this time
- Use a
private, well-lit room and ask patient to do the same
- Take
the patient’s phone number in case the video link fails
- Ensure
you have access to the patient’s clinical record (ideally, have it available on
a second screen)
- On the
day, check that the technology is working
Starting the consultation
- Initiate
the consultation by calling or inviting the patient
- Say
something e.g. “can you hear me?” “can you see me?” to
prompt patient to optimise the technical set-up
- Take
and record verbal consent for a video consultation
- Introduce
everyone in the room (even those off camera), and ask patient to do the same or
confirm that they are alone
- Reassure
the patient that the consultation is likely to be very similar to a standard
one, and that the call is confidential / secure
Having a video consultation
- Video
communication works the same as face to face, but it may feel less fluent and
there may be glitches (e.g. blurry picture)
- You
don’t need to look at the camera to demonstrate that you are engaged. Looking
at the screen is fine
- Inform
the patient when you are otherwise occupied (e.g. taking notes or reading
something on another screen)
- Make
written records as you would in a standard consultation •Be aware that video
communication is a bit harder for the patient
Closing
the consultation
- Be
particularly careful to summarise key points, since it’s possible something
could have been misssed due to technical interference
- Ask the
patient if they need anything clarified
- Confirm
(and record) if the patient is happy to use video again
- To end,
tell the patient you’re going to close the call now, and say goodbye (before
actually closing the connection)
4. How should patients prepare for, and participate
in, video consultations?
Patients, decide if video is right for you
- If you
just need general information and self-care tips, use a website (e.g. put ‘NHS
coronavirus advice’ into Google)
- You
don’t need a video consultation if a phone call will do
- Video
consultations provide more visual information and can be more reassuring if
you’re anxious
- Your
doctor or nurse may be self-isolating and working by video
- Check
your GP practice’s website to see what is on offer
Get
set up technically
- A good
internet connection
- A quiet
place where you won’t be disturbed
- A
computer, tablet or smartpone with a built-in camera and microphone
- Test
your audio and video connection and adjust the settings so you can see and hear
well (or get someone to do this for you)
- Check
your practice website for what else you need to do (different video platforms
have slightly different set-up steps)
Booking and connecting
- Make a
video appointment by following instructions from your GP practice (on the
practice website or answering machine)
- Just
before your appointment time, click the connection
- Say
hello or wave when you see the doctor or nurse (you may both have to fiddle a
bit to get the sound and picture working well)
- Make
sure the doctor or nurse knows your phone number so they can call you back if
the connection fails
Having your consultation
- Look at
the screen (there’s no need to look directly at the camera)
- If all
goes well, the call will feel like a face to face appointment
- Use the
screen camera to show things (e.g. a rash)
- If you
get cut off and can’t reconnect, wait for a phone call
- Write
down any advice or instructions, and make sure you understand the next steps
(e.g. where to leave a specimen)
- When
you’ve both said goodbye, disconnect
Preliminary template for a video consultation in primary care with a patient who may have Covid
This template is under development and may change
as new data emerges
Get set up technically
- Follow
local procedure to make the link
- Check
video and audio (“can you hear/see me”)
- If
necessary, prompt the patient to check and adjust their microphone (you
may need to call them on an ordinary telephone to troubleshoot this)
- Open
the patient’s medical record, preferably on a second screen
- Note
the patient’s phone number in case you need to call them back
- Get set up professionally
- Confirm
the patient’s identity (e.g. if not known to you, ask name and date of
birth)
- Ask
where they are right now (at home – or somewhere else?)
- Confirm
that you are alone (or introduce anyone else in the room, even if they are
off camera), and ask the patient to do the same
- Assure
them that the conversation will be private and confidential, like a
standard clinic encounter – Scan their medical record summary and tailor
the rest of the consultation accordingly
Begin the consultation
- Assess the patient visually (do they look sick? are
they distressed? too breathless to talk?) and go straight to key clinical
questions if appropriate
- Establish why the patient has chosen to consult
now, by video (e.g. are they or a family member very anxious?)
- Establish what the patient wants out of the
consultation (e.g. clinical assessment, sick note, referral, advice on
self-isolation, reassurance)
- Check medical record for high-risk status including
immunocompromised (diabetes, chronic kidney or liver disease, pregnancy,
chemotherapy, steroids or other immunosuppressants), cardiovascular disease,
asthma or COPD
Take a history
- Covid contact, especially confirmed cases with <
1m contact for > 30 minutes (incubation period is 2-14 days, mean 5.5)
- Is anyone else in the immediate family unwell?
- Travel to a known hot spot (e.g. put “WHO Situation
Report” into Google for latest)
- Temperature: how high? For how many days? (Covid
typically > 38.0 and persists beyond 5 days)
- Cough (dry, persisting for > 5 days)
- Shortness of breath
- Note date of first respiratory symptom to
date-stamp onset of disease
- Coryza and allergic symptoms make Covid less likely
- Gastro-intestinal symptoms are rare (< 5%) in
COVID but can occur
- Red flag symptoms for other serious conditions
(e.g. passing urine regularly? eating and drinking OK? severe headache? neck
stiffness? non-blanching rash?)
Remote examination
- General physical assessment e.g. skin colour, view
of pharynx plus assessment of relevant comorbidities
- Assess respiratory function: high respiratory rate
occurs only in advanced cases but inability to complete sentences is common in
Covid
- Assess relevant comorbidities
- Psychological assessment e.g. do they look upset or
distressed? Do you need to use a formal mental health instrument for
anxiety/depression?
- Are there relevant family issues in view e.g. small
children?
Tests
- Patient
may be able to take own peak flow, temperature, pulse, BP, and oxygen
saturation if they have instruments at home
- Bring
your own device into camera view to show them how to use their equipment
if necessary (they may have only recently purchased it)
- Fitbit-type
gadgets and smartphone apps may measure biomarkers but their accuracy can
be hard to judge
- Advise
on local procedure for how to undertake self-swabbing
- Discussion and shared decision making
- Share
information and explain uncertainties
- Provide
therapeutic presence (active listening, empathy)
- Offer
options and invite questions
- Advise
and reassure as appropriate
- Discuss
and agree on next steps
- Arrange follow-on as appropriate
- Unwell
and needs admission (> 999 protocol)
- Unwell
and needs monitoring
- Safety
netting: if becomes more unwell, difficulty breathing, faint, stops
passing urine, unable to keep down fluids, call GP or out of hours service
as appropriate
- Needs
management of comorbidities
- Needs
reassurance and clear advice on self-management
- Medication,
certification, home swabs etc
- Ending the consultation
- Ask if
anything else?
- Wish
the patient better, say goodbye and “I’m going to sign off now”
- Document and code the encounter on patient’s record
Source: BJGP,
Video consultations: a guide for practice by Trisha Greenhalgh, on behalf of
the IRIHS research group at the University of Oxford, with input from Clare
Morrison of Scottish Government Technology Enabled Care Programme and Professor
Gerald Koh Choon Huat from National University of Singapore