Primary Care | PRECISECAREMEDICAL

 Full spectrum or warm, white light (3200–4000 K) is suggested (Krupinski & Leistner, 2017; Major, 2005; PHSA, 2013) with a minimum light level of 150 footcandles (Belz et al., 2009; Krupinski, 2014). Colored lighting (i.e., from lamp glass), as well as color inherent to the technology (e.g., narrow-spectrum blue light from an LED) should be avoided, although some specific clinical applications may call for colored room light (Krupinski & Leistner, 2017). Means for controlling glare from natural and artificial light sources is also required. For example, shades or blinds can reduce light and glare in rooms with windows (CTEConline, 2011). It should also be possible for clinicians and/or patients to avoid sitting in front of a window unless backlighting can be adequately addressed.

 Eye contact is an important aspect of visual communication, but when using a webcam, perceptions of eye contact are affected by the location of the camera (Chen, 2002). In videoconferencing (and telemedicine), a webcam is typically positioned on top of the monitor or laptop screen. As shown in Figure 3, the resulting angle between the eye and the camera, and the eye and the center of the display, the visual target, is the gaze angle (Grondin et al., 2019; Tam et al., 2007).

 Research has established that due to our perceptions, videoconference/web cameras should be placed above the screen monitor, preferably resulting in a gaze angle less than 5º (Chen, 2002). Additional research highlights that even what might seem like insignificant changes make a difference in our perceptions. For example, when Tam and colleagues (2007) studied differences in gaze angle, they found a lower angle (7º or less) resulted in perceptions that the subject was ‘happier,’ ‘warmer,’ ‘more approachable,’ ‘more confident,’ had ‘better rapport,’ was ‘more engaged,’ and more interested in what the observer had to say. At a higher angle (15º), perceptions were more negative with perceptions that the subject was ‘reserved,’ ‘shy,’ ‘timid,’ ‘sad,’ ‘depressed,’ ‘stoned,’ ‘lost,’ ‘hiding something,’ ‘not being forthcoming,’ looking through the observer, distracted by something, not focused/engaged in the conversation, and not giving full attention.

 A more recent study tested the use of a gooseneck webcam mount to lower the webcam over the edge of the monitor screen, along with a slightly raised chair height (Grondin et al., 2020). Grondin and colleagues (2020) found this allowed a decrease in the gaze angle down to 2.5°, mitigating conditions of “downward tilting” eyes that result when the webcam is mounted in a traditional location. Camera placement can also be a barrier to communication. In one study, patients felt unheard and perceived that the provider was not paying attention due to lack of eye contact when the provider looked back and forth from the computer monitors (Gordon et al., 2020).

 When using a larger freestanding monitor, this may mean greater viewing distances—for example, 4'11" for a 42" monitor up to 8'2" for a 65" monitor (Ben-Arieh et al., 2016). While a “passport” picture view (head and shoulders) is suggested for introductions, the camera may subsequently be adjusted (or zoomed in/out) for a better view of the body and any non-verbal cues (Ben-Arieh et al., 2016; Grondin et al., 2019; Nguyen & Canny, 2009).

 The distance between walls determines the patient to camera proximity, and this may vary by service depending on desired “framing” (how much of the head and/or body is viewed): a full view of the patient and others, a view of the upper body to recognize non-verbal cues, or just the face (Raymond et al., 2016). In some specialties, such as dermatology, there may be a need for close-up and wider views for context (ATA Teledermatology Guidelines Work Group & ATA Practice Guidelines Committee, 2016). A small room can force the camera to be located too close to the patient, limiting the clinician view (CTEConline, 2011).

 Framing of the view was found to be important in providing the desired “psychological” distance for both clients and therapists in telepsychotherapy (Grondin et al., 2020), as well as perceived empathy (Nguyen & Canny, 2009). The distance and range of view may influence other perceptions, as well. For example, the view of a desk in services such a telemental health is not universally accepted—some experts suggest the view of a desk can create a “buffer zone,” but others feel it may be perceived as an obstacle (Raymond et al., 2016).

 The finishes and colors selected for a telemedicine space must be able to support the natural rendition of color and pattern. All sources referenced in the development of the text were consistent in finding that light to medium blue or light gray matte finishes (Figure 4) are best for proper color rendition and facilitating picture clarity (Belz et al., 2009; CTEConline, 2011; Krupinski, 2014; Major, 2005; PHSA, 2013). These shades are preferred because they offer minimal light absorption and light reflectivity (Belz et al., 2009). If a space is used for other functions, screens or curtains may be used to provide the appropriate background color or to hide clutter (Krupinski & Leistner, 2017).

 The FGI Guidelines require the backdrop wall color to have a light reflectance value of 30-40%. To avoid glare and reflections, a surface finish rating of level 1 or 2 (flat finish) is recommended rather than a gloss rating of level 5 (semi-gloss) or 6 (gloss finish). Recommendations for avoiding glare and contrast include specifying light reflectance values for surfaces: 80-90% for ceilings, 25-45% for furniture, and 20-40% for flooring (Facility Guidelines Institute, 2018b).

 Facility identification must be provided at the telemedicine site so it appears in the transmitted image unless such identification is embedded in the electronic telemedicine platform (Figure 5). This signage is sometimes required for reimbursement but is also helpful for reminding clinicians and patients where the person they are speaking with is based when telemedicine services are offered between multiple locations (Major, 2005; PHSA, 2013).

 Secure storage is required for telemedicine spaces where portable equipment and peripheral devices (e.g., digital cameras, task lighting, EKG devices, etc.) are used (Krupinski et al., 2007; PHSA, 2013). Additional guidance for equipment used for telemedicine services includes provision of temperature controls based on the heat the electronic equipment may generate (Charness et al., 2011; CTEConline, 2011); this is also a consideration for the comfort of the patient who may be unwell. Depending on the complexity of equipment used, multiple outlet types (e.g., phone, data, power) may be required (CTEConline, 2011). Locating required outlets near any equipment will mitigate the risk of hazards such as cords and cables across the floor (Charness et al., 2011). Finally, select and install telemedicine equipment to facilitate cleaning and support infection prevention practices (Krupinski et al., 2007).

 “Telehealth is not about technology, it’s about people” (Martínez-Alcalá et al., 2013). Telemedicine and telehealth have evolved quickly over the past few years, and notably, the past several months, suggesting this aspect of healthcare will now be accepted more than ever as the “new” way of doing business. As technology advances and organizations become more familiar with platforms and service options, minimum built environment standards to support these practices may need to be refined.

 Language in the FGI Guidelines has been established with a small amount of verbiage as required minimum standards and more extensive recommendations in the appendix, allowing flexibility for organizations to ascertain their own level of need based on services rendered. As the industry evolves and more evidence is made available, some design requirements may also evolve with practice guidelines. However, while remote communications via electronic equipment can be a necessary supplement to in-person care, especially in a pandemic context, the design of telemedicine spaces should facilitate natural communication for the widest range of participants, including elderly patients, those unaccustomed to electronic communication, and those with vision, hearing, or cognitive impairments. Designing spaces used for telemedicine communications should always strive to maintain the level of safety, privacy, quality of care, and patient experience that would be expected for that same communication when it takes place in person.

 The College recognizes the role virtual care plays and will continue to play in the provision of medical care to Nova Scotians.

 The medical profession is still learning about the strengths and limitations of virtual care. The decision by a physician to provide virtual care requires an exercise of professional judgement considering the circumstances and condition of the patient.

 The regulation and provision of virtual care is quickly evolving. The College will be revisiting this standard on a regular basis to keep pace with this evolution.

 Physicians licensed in Nova Scotia who deliver virtual care to Nova Scotians are subject to the regulation of the College, irrespective of where the physician is located.

 Physicians licensed in Nova Scotia who deliver care into other jurisdictions in Canada will be held to the standards of that jurisdiction, while subject to the regulation of this College.

 Physicians licensed elsewhere in Canada who deliver virtual care into Nova Scotia will be held to Nova Scotia standards but subject to the regulation of their licensing authority.

Primary Care

 1. offer virtual care to patients only in conjunction with in-person care, not as an absolute alternative to in-person care;

 2. coordinate their clinical schedules so that patients have reasonable access to either in-person care or virtual care as required;

 Physicians are encouraged to review the College’s Professional Standards and Guidelines Regarding Informed Patient Consent to Treatment. In addition to the requirements of this document, the patient-consent process for virtual care services must ensure the following information is reviewed by the patient:

 In reference to the new Nova Scotia Department of Health and Wellness policy, “Provision of Publicly Funded Virtual Health Services”:

 “Patients have the right to choose an in-person visit and/or refuse a virtual appointment. Health professionals will work with patients to determine the best modality for the patient encounter (in-person or virtual) while adhering to practice standards, protocols, and Public Health guidelines outlined by relevant health profession regulatory bodies/DHW/NSH/IWK and using professional judgement, while also prioritizing patients’ preferences and needs for virtual or in-person encounters. Offering virtual visits should not contribute to increased patient isolation.”

 provide care consistent with accepted standards of practice. Virtual care must not compromise the standard of care;

 not prescribe opioids or other controlled medications to patients whom they have not examined in person, or with whom they do not have a longitudinal treating relationship, unless they are in direct communication with another regulated health professional who has examined the patient;

 not prescribe opioids or other controlled medications to patients whom they have not examined in person, or with whom they do not have a longitudinal treating relationship, unless they are in direct communication with another regulated health professional who has examined the patient;

 inquire whether the physical setting in which the care is provided is safe, appropriate and provides for confidentiality;

 use virtual care systems that ensure confidentiality. If not possible, inform the patient that the method of virtual care does not guarantee confidentiality. Disclose the risks of a virtual visit and obtain verbal consent and record in the chart;

 Physicians must review the Nova Scotia Personal Health Information Act. Note that certain communication technologies may not adequately protect the security of personal-health information. Physicians may wish to consult with the Canadian Medical Protective Association.

 if the physician determines that an in-person assessment is required, the physician must schedule an in-person assessment as soon as the patient’s presentation requires; and

 if the physician determines that the patient needs to be seen in-person by another physician or discipline, the physician must advise the patient, direct the patient accordingly and document their reasoning.

 Across the nation, hospitals and health systems are reshaping virtual care programs to be more accessible, affordable and responsive to patients, clinicians and care teams. The challenge is: How do you capture best practices of in-person visits and evidence-based medicine while adapting to the unique setting of virtual care?

 Four leaders of clinical transformation, innovation and marketing from The University of Texas MD Anderson Cancer Center (MDACC) and Texas A&M University’s Mays Business School recently shared a blueprint in the Harvard Business Review.

 The so-called “DIBS” framework — documentation, integration, best practices and support — offers benefits for all virtual care stakeholders. The report provides insights drawn from implementing a suite of virtual care services at MDACC and operating procedures and virtual care guidelines at other institutions, including the University of Pittsburgh Medical Center (UPMC) and Jefferson Health.

 Include all unique activities of health care staff for a typical virtual care encounter. Compare and contrast in-person and virtual care contexts based on the patient’s reason for the visit. This comparison can help uncover process complexities that may arise unexpectedly when transitioning from in-person to virtual care. Categorize care-related activities before, during and after the visit and guide the technical assistance process for patients who have specific visual, auditory, language, technology literacy or technology infrastructure needs.