Clinic Arrangement and Telehealth
To minimize the possibility of cross contamination and nosocomial infections within hospitals, the majority of routine clinic appointments were postponed(5). 80-90% of outpatient service have been cut to leave only urgent or semi-urgent conditions to be seen. During this two-month period, 3800 cases have been rescheduled at the outpatient clinic. The number of doctors seeing consultations was reduced significantly, with one dedicated clinician with full personal protective equipment(6) and fit tested N95 respirator performing aerosol generating procedures such as a flexible laryngoscopy, to conserve personal protective equipment (PPE) during clinics. In addition, each doctor sees only 10-15 patients per consultation session, representing a reduction of caseload by at least 40% for each doctor, allowing the time needed for strict compliance of infection control measures. All doctors wore a gown, cap, gloves and surgical mask to see patients(5) and all patients were required to wear a surgical mask before entering the hospital. A dedicated drug refill clinic was also set up to allow stable patients to obtain a repeat prescription without consultation and new appointments were rescheduled based on their clinical condition.
To deal with the accumulation of rescheduled cases, the department may need to set up extra clinic sessions in the evening or during weekends once the pandemic is settled. It will take about 44 weeks with an average of 2 extra sessions per week to tackle the accumulated cases. In order to avoid excessive rescheduling of appointments, our hospital has started utilizing tele-medicine in clinical practice during the pandemic since February 2020. 2 sessions were organized per week for each doctor with 6 consultations per session. Telemedicine sessions took up to 10 minutes longer when compared to a face to face consultation of usually less than 10 minutes per patient.
To accomplish these telemedical sessions, Zoom was adopted by the hospital as an app in compliance with Health Insurance Portability and Accountability Act Security Standards to ensure the security and privacy of protected health information. This platform for telemedicine was endorsed by the Central Credentialing Committee, Hospital Authority, Hong Kong. The spectrum of telemedicine service included consultations by doctors and nurses, outpatient wound care, palliative care at home and academic meetings or multidisciplinary tumor board meetings. However, there have been recent concerns over the potential vulnerability with Zoom, in which ‘Zoombombing’ or hijacking during video conferencing(7), and privacy concerns have been raised. The Hospital Authority in Hong Kong underwent a series of security assessments on the updated Zoom client, confirming that data sharing with social media was no longer allowed. The analysis reported that the vulnerabilities have been resolved and end-to-end encryption was also enforced. To protect our patients, the Information Technology department of the Hospital Authority recommended clinicians and patients to use the latest version of the Zoom client and to use the Zoom client with a corporate account to enjoy enterprise security features. Furthermore, a password should be set for every meeting and the meeting details and password should be exclusively disclosed to participants only. Finally, the “Lock” function should be enabled once all participants have joined the meeting to avoid intrusion.
The key to the successful operation of telemedicine consultations was patient selection.
Ideal cases would be patients with routine follow-up whom physical examination might not add critical information. Patients’ age and education were also taken into consideration. Patients who were enrolled into telehealth had to possess a smart device with a web camera and be able to use the Zoom web conferencing app. In head and neck patients, telemedicine could be utilized to reduce patient’s travel and hospital attendance to minimize the risk of cross infection. After the initial attendance for examination and consent, further preoperative counselling, education of postoperative care, dietary advice and neck and shoulder exercise recommendations could all be delivered by telemedicine. In the postoperative phase, simple wound review and troubleshooting could also be performed.
To ensure the correct patient was seen at the right time using Zoom tele-conference, the appointment date and time, Zoom conference ID and password were sent to patient’s email and phone using SMS. Two-way ID verification was then adopted. Patients were asked about their date of birth or the last 3 digits of their Hong Kong identity card number and they were asked to show their unique outpatient appointment slip to the web camera. After each consultation, a new appointment slip and prescription sheet would be mailed to the patient by post. At the same time, an electronic appointment slip and prescription would be sent to patients through e-mail or the hospital telehealth app. Patients could then go to the Pharmacy within 7 days to obtain the prescribed medications. (Figure 1)