Fully Virtualized Precepting and Patient Care in Fellow and Resident Continuity Clinics

The COVID-19 pandemic has necessitated a rapid shift in our traditional clinical care delivery model: To preserve physical distancing and avoid risk to vulnerable patients, telehealth visits have increased as in-person visits are canceled. Telehealth visits are defined as office visits that occur using an interactive 2-way telecommunications system where the provider is at a different location from the patient. Center for Medical Services rapidly changed requirements for reimbursement and billing of televisits to accommodate this new reality. 

At our institution, prior to the COVID-19 pandemic, telehealth visits comprised 2% of ambulatory visits, and now have increased to over 58% of ambulatory office visits. Initially, telehealth visits were conducted by attending physicians only. UCSF affiliated medical centers rapidly explored how to preserve resident and fellow continuity clinics while still allowing for virtual precepting and patient care. Attending preceptors, patients, and trainees all log-in remotely from their own homes. Our institution’s health IT team assessed Zoom platform implementation for telehealth to ensure it met security requirements imposed by HIPAA. Patients were given explicit instructions electronically through the patient messaging portal (Epic MyChart) on how to install the Zoom video software and log-in using their own unique ID. 

Using Zoom, trainees initialized the patient visit in their own virtual Zoom room. When ready to precept, trainees would text preceptors using secure messaging to indicate readiness to precept, and place the patient in the Zoom “Waiting Room.” The attending preceptor would access the visit through a Zoom link and be admitted to the meeting by the trainee. After the trainee and faculty discussed the case, the trainee would re-admit the patient to the room to initiate a three-way conversation. After answering questions and evaluating the patient, the faculty member could leave the Zoom meeting and the trainee would finish up the visit and complete the documentation. 

Pulmonary/critical care fellow continuity clinics, internal medicine resident continuity clinics, neurology continuity clinics, and endocrinology continuity clinics, among others, were many of the programs that fully transitioned to the virtual precepting platform. Patients and families reported satisfaction in ensuring continuity of care and trainees appreciated the opportunity to continue to care for their patients and still engage in real-time teaching from clinical preceptors. The virtual precepting model ensured continuity of care, community-building between trainees and faculty, and maintained physical distancing. This approach can be easily replicated at other institutions using an EMR and secure videoconferencing. 

Not all patients are able to conduct video visits due to lack of smart phones/tablets/secure internet. This was found at all of our clinic sites but even more notably at our safety-net hospital and VA sites. Recognizing that the move to video visits may exacerbate inequities, we continue to offer telephone visits for patients who are unable to conduct video visits. In these cases, precepting still occurs via phone. Moreover, one of our medical centers required some providers to physically be on-site, thereby prohibiting a fully virtualized continuity clinic. Overall, the innovation was most successful at our Epic-EMR based sites, but raised concerns for ongoing inequities among patients who lack access to this technology.