Barton Schmitt, MD, FAAP

Telemedicine (TM) video visits were off to a slow start in most offices and clinics in 2020. Then along came the COVID-19 pandemic and TM care took off. To prevent the spread of the virus, primary care providers (PCP) transitioned from in-person visits to providing as much definitive care as possible by video visits. Being able to bill at in-person rates was an added motivator. The PCPs quickly adapted, overcoming concerns about learning video visit technology. Reports that a significant percentage of contagious patients with the virus were asymptomatic increased their interest. Families who were afraid of catching COVID-19 in a medical setting welcomed a video visit option. Convenience was an added incentive. This report reviews how to optimize teamwork between telephone triage nurses and PCPs who provide video visits.

Repurpose telephone triage protocols to support telemedicine visits

Nurse triage continues to be a vital part of how we manage our patient populations. Nurses can use the triage questions and care advice as written but modify the dispositions to include a TM option. Most of the dispositions simply need to be changed by adding “or schedule a video visit” to the existing “in person visit” wording (Table 1).

1­. Triage questions that fall under the 911 or Go to emergency department (ED) Now dispositions. These indicators recognize serious conditions where delay in diagnosis and treatment could lead to adverse outcomes.

2. ­Patients who are nurse-triaged to the Home Care dispositions. They usually don’t need PCP involvement.

Use nurse triage to front-end PCP telemedicine visits

Office triage nurses can continue to independently manage most calls about well children (such as eating, sleep, behavior, vaccines, and new baby questions). During office hours, these may account for 30% of pediatric calls.

For calls about sick children, each practice will need to decide if nurses continue to triage all of them or just some of them. If the practice wants nurses to triage all sick child calls, up to 50% will be triaged to the Home Care disposition (mildly ill and don’t need to be seen). Nurses then refer the patients who need to be seen to the PCP for an in-person or video visit.

Some practices prefer to let the parent decide. After knowing the reason for the call, the front desk staff can ask: “Do you want an appointment with the doctor, or do you want to talk with our advice nurse?” If they want to be seen, schedule an in-person appointment. If a parent prefers a video visit, it can only be scheduled after a triage nurse or PCP confirms the main symptom is appropriate for TM. For TM visits, the timeframe should be similar to the protocol-recommended timeframe for office visits or sooner if TM is readily available. Many PCPs still prefer in-person visits over video visits, because they can provide definitive care more quickly in the office.

Help triage nurses select patients for a TM visit

Many will validly argue that TM can’t manage all patients who are triaged as needing to be seen. Some offices found a solution. It’s called a “split visit.” A TM visit is attempted on almost all patients who would be triaged to an office visit. Most of the time, it is successful without a complete physical exam or any lab tests. When not, the patient is sent to the office soon after the call. The office visit can then be a brief encounter, such as to perform a rapid strep test or an ear exam, sometimes in the office parking lot. If 2 visits are required, reassure payors, only 1 fee should be generated.

For offices who want the nurse to more carefully select candidates for TM visits, here are some guidelines. If we tried to establish inclusion criteria, it would be difficult to reach a consensus. Establishing exclusion criteria for TM visits has greater consensus and leads to a far shorter list.

Some offices where a physician and nurse have worked as a team for many years may not need such a list. Nurse judgment from working closely with a PCP might allow the triage nurse to select appropriate patients for TM visits. When in doubt, office nurses can ask for guidance. However, for triage nurses in many office practices, an exclusion list of patients not appropriate for a TM visit is helpful. See our suggested list as a place to start and modify to meet your needs.

Telemedicine exclusion list for office triage nurses

The Telemedicine Exclusion List in Table 2 is a work in progress. It will need to be customized by most primary care practices. Some software platforms with protocols in electronic format support customizing specific triage questions that are not appropriate for TM. Nurse awareness of PCP preferences also play a role in deciding who is appropriate to refer for TM. In our experience, most suspected COVID-19 calls and symptoms are being managed by TM visits.

Another decision is where to start. Table 3 lists the nurse triage protocols most amenable to TM care. They are protocol symptoms with high call volumes. They also have a high likelihood that a video visit can provide diagnosis and treatment.

Telemedicine video visits are part of the new normal. Most PCPs have learned how to provide them. Families appreciate their convenience and safety from COVID-19 contact. And they want the service provided by their PCP, not an unknown provider. In addition, the PCP can seamlessly convert a video visit into an office visit when needed.

During office hours, office triage nurses can schedule TM visits in real-time. On weekends and holidays, call center nurses can schedule patients triaged to the video visit within 24 hours disposition with on-call PCPs who are willing to provide this service during the day. These are the patients who otherwise might need referral to an ED or urgent care venter (UCC) over the weekend. In summary, what we have learned from managing calls about suspected COVID-19 infections is that there is no “going back”.

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COVID-19 has brought telemedicine to the forefront of medical care. Here's some strategies that can help streamline the process, using teamwork.

Barton Schmitt, MD, FAAP

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