Enhancing Management of Chronic Conditions Using Virtual Care During COVID-19

Last Updated: February 23, 2021

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Virtual care is any remote interaction between patients and their circle of care, involving the use of phone, video, email or secure messaging (WIHV, 2015). With some upfront time and effort, virtual care can lead to a more efficient practice and better quality of care both during the pandemic and after. This resource is designed to improve provider confidence in implementing virtual care to support quality chronic disease management.

Why virtual care?

Using virtual care for chronic disease management can help you:

  • Save time by avoiding visits to titrate medications or track side effects by collecting information on symptoms and risk factor control through email/secure messaging
  • Shorten or reduce follow up visits for chronic disease management by sending educational resources and plans for escalation of care
  • Save administrative staff time by using email/secure messaging for preventive care (vaccinations, OBSP, CRC screening) and recalling patients for overdue visits
OntarioMD Peer Leaders

A network of 60+ clinicians who offer free, direct support to assist healthcare providers in selecting and implementing health technologies that will best serve their unique needs.

eHealth Centre for Excellence

Provincially funded change management services to support primary care providers with the adoption of virtual care, with the goal of improving timely access to primary care and ensuring that all patients in the region are getting the care they need, when they need it.

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Tips to improve effectiveness and efficiency when providing virtual care

Improved encounter efficiency
  • Prior to encounters and in-between virtual visits, send patients digital symptom scores or surveys to assess for exacerbations. Secure messaging platforms may include premade tools and validated scales.
  • Use patient-facing triage questions.
  • To replace follow-up visits by telephone or video, ask patients to follow-up via secure email or messaging at specified time intervals to report response to treatment and changes in symptoms.
  • Be flexible with modalities. Supplement a telephone visit with video for a comprehensive physical exam or followup a telephone call with an email to clarify instructions.
More effective patient self-management
  • Send patients an action plan, with instructions on how to address changes in disease status (e.g. titration of medication) and red flags for when to seek care.
  • Have patients use home monitoring devices (e.g. BP cuffs, weight scales) to monitor and support action plans.
  • Connect patients with free, virtual programs to support self-management skills.
Increased opportunities for proactive care
  • Consider screening patients who are at risk of conditions that impact chronic disease and who may worsen during the COVID-19 pandemic.
  • Certain patients may benefit from enrollment in more intensive remote monitoring programs available in your region.
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Tips for practicing patient-centred virtual care

Assess patient preference and capacity
  • Identify language, visual or hearing barriers.
  • Confirm tech literacy.
  • Confirm access to technology and internet connection.
  • Confirm access to private space for virtual visit. For example, “Are you in a private room?” or “Can anyone overhear your conversation?”
  • Ask which modalities patients are comfortable with. For example, “How often do you use video-conferencing technology?”
  • Consider privacy or security concerns. See CMPA for specific considerations.
  • Consider the need for “face-to-face” connection to support patient and therapeutic relationship.
Enable patient access
  • Canada’s Connecting Families program provides subsidized internet access for those eligible.
  • Find ways to increase tech literacy, (e.g. have family or friends provide lessons or support a virtual visit).
  • Run a donation drive to collect devices for patients.
  • Support patients and caregivers to obtain and use home monitoring devices.
  • Facilitate access to hearing and other communication aids. See MOH Assistive Devices Program.
  • Facilitate access to visual aids. CNIB technology programs provide skills and training, as well as accessible/affordable technology.
Strengthen the patient-provider relationship
  • Describe your behaviours aloud during virtual visit, such as looking-up information or note-taking. This can prevent the misinterpretation of silence or a pause.
  • Ask direct questions about a patient’s emotional state. Visual cues may be lacking in virtual care visits.
  • Show attentiveness by making affirming sounds as patient speaks.
  • Avoid multi-part questions if the phone or internet connection is causing delays or lags.
  • Be aware of the patient’s health literacy. Avoid acronyms and words that are not suitable for a lay audience.

Tips to integrate virtual care into your workflow

1. Make a plan

Include all team members when planning virtual care improvements, especially administrators. Discuss how to communicate changes to patients.

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2. Record patient consent

Discuss the risks of virtual communication with your patient and document their consent. For subsequent virtual interactions, provide a brief reminder of the risks.

Supporting resources
  • See CMPA (2016) for a sample consent form
  • See OntarioMD for verbal consent scripts/EMR documentation examples
  • See OntarioMD: Privacy and Security Training Module which covers compliance with PHIPA and the Personal Information Protection and Electronic Documents Act (PIPEDA), consent requirements and privacy policies in the context of virtual care.
3. Prepare patient

Give patients guidance on participating in virtual visits. Use pre-visit measurement instruments to increase appointment efficiency. See below for more tips on increasing encounter efficiency.

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4. Manage documents

Managing documents (e.g. signing and faxing) may require additional software or workflows when working virtually.

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5. Modify schedule

Consider scheduling similar types of appointments together (e.g. telephone appointments in the morning, video visits in the afternoon). Asynchronous communications in-between virtual care visits, when appropriate, can reduce the length and complexity of encounters.

Modalities to support virtual care in practice: email and secure messaging

There are benefits to using email and secure messaging. Asynchronous virtual visits facilitate proactive care and patient self-management, supporting continuity and quality of care for patients. 

Health care providers may feel hesitant when adopting email and secure messaging, particularly about:

  • A lack of compensation for the time invested 
  • Unrealistic patient expectations about provider response times and frequency of visits 
  • Privacy and security concerns
  • Feeling overwhelmed with the amount of requests and messages

Use email and secure messaging to save time

Some providers feel that the time saved by using email and secure messaging justifies their use, despite the lack of compensation
received and time invested. Consider the value of these tools for your clinic and inform patients of their correct and expected use.

Ideal for:
  • Follow-up and monitoring symptoms
  • Receiving documents, photo and data collection to supplement virtual visits
  • Patients with higher-tech literacy/access
  • Patients with hearing and/or visual barriers
Not ideal for:
  • Emergencies or when information is needed urgently
  • Difficult conversations
  • Addressing more complex issues
  • Patients without access to a computer/internet connection

Appropriate use for providers and patients
Providers DO use email/messaging for:
  • Responses to simple questions about medications or medical issues that have been discussed at another visit
  • Ongoing monitoring of parameters like blood pressure or blood sugar
  • Notifications about tests due or appointments to make
Patients DO NOT use email/
messaging for:
  • Emergencies or when information is needed urgently
  • Requesting medical advice that is not for themselves
  • Exchanging sensitive medical information
  • Requesting a diagnosis based on a description of symptoms
  • Frivolous or commercial purposes

Ensure privacy and security when using email and secure messaging

What email services can I use?
  • Reasonable steps must be made to use encrypted virtual communication with patients.
  • Gmail, Yahoo and other large consumer email services are allowed for some patient exchanges, but do not support a completely secure exchange of information.
What email services can I use?
  • Reasonable steps must be made to use encrypted virtual communication with patients.
  • Gmail, Yahoo and other large consumer email services are allowed for some patient exchanges, but do not support a completely secure exchange of information.
Addressing email privacy and security concerns
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Addressing privacy and security concerns

  • Discuss with patients the increased privacy risks when using large consumer email services (e.g. not PHIPA compliant) versus their benefits (e.g. ease of use, accessibility). Obtain documented consent to communicate with patients using such services. See CMPA: Consent to use electronic communications (2016) for more details on obtaining consent for email.
  • Use secure email services designed for health care professionals. For those currently using ONE Mail Direct, Ontario Health will retire the service in 2021 and is currently not on-boarding any new clients. TeraMach (2021) has been identified as the qualified vendor and will be an equivalent secure email service. There will be a fee for migrating accounts over to the new service and an ongoing cost for using the new system. Please note that informed consent from patients is still required when using these platforms.
    • OntarioMD: Privacy and Security Training Module covers compliance with PHIPA and the Personal Information Protection and Electronic Documents Act (PIPEDA), consent requirements and privacy policies in the context of virtual care. Up to 2 CME Mainpro+ credits are available for those accessing the module.
  • Health care professionals should use secure email with one another when transferring or sharing patient personal health information, unless there is an emergency. CPSO, CNO and OCP have made an exception to allow the use of unecrypted email for the purpose of sending prescriptions to a pharmacist during COVID-19. Consent must be obtained from the patient for this purpose.For more information on PHIPA compliance from the colleges, see:
What is secure messaging?
  • Secure patient messaging platforms are PHIPA compliant and support secure messaging between patients and providers. Messages may be one-way (provider-to-patient only) or bidirectional (initiated by either patient or provider). See OntarioMD’s Direct-to-patient virtual and digital tools for practice and CMPA: Consent to use electronic communications (2016) for more details on obtaining consent for secure messaging.
  • Generally, a link to the message is sent to a patient’s email, routing them to a secure platform where they can read and respond to it.
  • Most platforms enable structured data collection through digital surveys. Many have a library of pre-made tools that clinicians can use.
  • Many platforms are EMR-integrated with privacy safeguards (e.g. patient authentication). Most have additional monthly fees.

Integrate email and secure messaging into your workflow

Clinic email
  • Consider setting up at least one clinic email. Set up an automatic reply for all clinical emails that inform patients when they can expect a response and when to seek care immediately.
  • Train team members to triage emails and messages.
  • Set up a dedicated email address for collecting patient documents, photographs and data. A team member can monitor and add files to the medical record.
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Patient communications
  • Communicate to patients about appropriate use and expectations for email/secure messaging, including response time, subject lines, etc.
  • Use email/secure messaging for patient campaigns (e.g. virtual care available), patient experience surveys (e.g. QIP), preventive care (e.g. vaccinations, cancer screening) and recalling patients for overdue visits (e.g. pap smears, diabetes visit, etc).
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Documentation
  • Clinically related emails/secure messages should be recorded in your EMR. If you are using a service that is not integrated into your EMR, copy and paste emails/secure messages into the patient’s record, or print and add to your paper records.

Provider self-care
  • Schedule and block of time to address patient messages and emails.
  • Limit the number of characters or words patients can use to make short, concise requests or comments.
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Modalities to support virtual care in practice: telephone and video

Telephone and video visits allow patients and providers to meet in real-time from different locations, allowing for live discussion, examination and delivery of care. Virtual visits can enhance the quality of care when patients and providers cannot meet in the provider’s office.

Health care providers may feel hesitant when adopting synchronous virtual visits, particularly about: 

  • Appropriate use for telephone and video visits
  • Setting up virtual visits in a primary care practice 
  • Billing
  • Managing workflow with virtual visits

Below we offer tips to address these concerns and helps providers enhance their practice by using telephone and video.

Determine if a telephone or video visit is most appropriate

Telephone
Ideal for:
  • Patients with low-tech literacy/access
  • Triaging clinical presentations
  • Less-resourced or paper-based clinics
  • Addressing a broad range of primary care concerns
Not ideal for:

  • Exams and assessments when non-verbal cues are important
  • Patients with language and hearing barriers


Video
Ideal for:
  • Patients with higher-tech literacy/access
  • Clinical concerns where non-verbal cues are important
  • Building, maintaining and strengthening the therapeutic relationship
  • Visual physical exam or non-verbal cues
Not ideal for:

  • Patients without access to a computer/internet connection 
  • Patients with visual barriers
  • Clinics without resources for up-front work to set up

Set up virtual visits in a primary care practice

Telephone
  • Blocking numbers: To block your telephone number when using a personal telephone, press *67 on Android or landline telephones or #31# on iPhones.
  • Masking numbers: Some patients may not answer blocked numbers.  You can purchase apps that display your clinic/office number to patients from a personal cell phone. Masking can be bi-directional and patients’ calls can be forwarded virtually to your administrative support staff.
  • Patient consent: Ensure that patients consent to virtual care and understand the risks and limitations associated. Make note of patient’s consent in your EMR.
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Video
  • Selecting a platform: Choose a video platform by considering many factors (e.g. cost, participants per call, familiarity to patients, limits on call length, screen sharing or text chat capabilities).
    • Consumer platforms are widely available, familiar to patients and easy to use (e.g. Skype, Microsoft Teams, Facetime, Zoom, Google Hangouts). Configure settings to optimize privacy.
    • Healthcare-specific video platforms are designed for virtual visits. These are more secure and may integrate into EMRs. Note — there may be additional costs associated with these platforms.
  • Hardware: A webcam and microphone are required. Consider earphones for better sound quality and patient privacy. Internet speeds above 10 Mbps are ideal (use speedtest.net to test).
  • Patient consent: Ensure that patients consent to virtual care and understand the risks and limitations associated. Make note of patient’s consent in your EMR.
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Bill for virtual visits

Telephone and Video
  • Use the new OHIP K-Codes and any applicable premium top-ups to ensure appropriate compensation for virtual visit appointments. The new fee codes are platform agnostic; any direct-to-patient telephone and video calling platforms can be used. For OTN users continue to use the OTN billing codes and any applicable premium top-ups.
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Integrate telephone and video visits into practice

Telephone
  • Physical exams: You may perform a limited physician exam by telephone, including patient-assisted maneuvers and assessments of older adults.
  • Supplement With email/secure messaging: Use email/secure messaging to collect images of symptoms, send and receive treatment plans, encourage patient self-management and for follow-up and monitoring.
  • Provider self-care: Being on the telephone can be tiring. Break up your day by intermixing different modalities or limiting the number of video visits each day.
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Video
  • Have a backup plan: Confirm the patient’s telephone number in case of technical difficulties with the video platform.
  • Physical exams: Many physical exams can be adapted for video.
  • Supplement With email/secure messaging: Use email/secure messaging to send and receive treatment plans, encourage patient self-management and for follow-up and monitoring.
  • Provider self-care: Being on video can be tiring. Break up your day by intermixing different modalities or limiting the number of video visits each day.
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Additional supports and resources New

Learn from another practice
Supporting patient-centred virtual care
Condition-specific patient supports
Self management programs
Remote monitoring programs/supports