Using Virtual Visits to Care for Primary Care Patients With COVID-19 Symptoms

Data Collection and Analysis

A retrospective electronic health record (EHR) review was performed to examine records of patients presenting to a community-based academic family medicine practice between March 3 and 31, 2020, with symptoms associated with COVID-19. This practice cares for a racially/ethnically diverse population of patients with insurance plans that include private indemnity insurance and government plans (ie, Medicaid and Medicare). Patients were identified in 2 ways: (1) staff kept detailed lists of patients whom they screened for fever, cough, or shortness of breath; and (2) 2 reviewers assessed scheduling notes describing the reason for a patient’s visit to identify those with other potential COVID-19 symptoms (ie, sore throat, nasal congestion, headache, fatigue, myalgias, nausea, vomiting, diarrhea, loss of taste or smell).⁴ Data abstractions were performed through April 20, 2020, to assess patient follow-up encounters.

Patients were characterized by demographics; health; type of initial visit (telehealth, telephone, in person); subsequent in-person encounter, emergency department visit, or hospitalization; symptoms reported; and outpatient testing and treatment. The “initial visit” is defined as the first encounter with a physician, whether by telehealth, telephone, or in person. The total number of patient interactions with the office regarding patient presenting symptoms was quantified. These represented the entirety of patients’ subsequent primary care interactions. Interactions included electronic messages, telephone calls, and physician telehealth, telephone, or in-person encounters. Telephone calls and electronic messages included both physician and staff interactions and included exchanges about accessing and using telehealth visits. Communication with staff before the initial visit with the physician was not used for classification of the initial visit type but contributed to the total number of interactions with the practice. The University of California, Los Angeles (UCLA) Institutional Review Board deemed this study exempt from review.

Stata 16.1 (StataCorp) was used for analyses. Chi-squared statistics and analysis of variance were used to assess differences (in patient characteristics, number of interactions with the office, outpatient testing, and medications prescribed) among patients receiving telehealth, telephone, and in-person visits.

Practice Change during Data Collection Period

In response to reports of local COVID-19 infections, the practice implemented a process on March 3, 2020, to convert selected scheduled office visits to either telehealth or telephone encounters. Staff phoned patients before scheduled office visits and administered a brief screening instrument to assess the presence of fever, cough, or shortness of breath. Patients exhibiting one or more symptoms were encouraged to have a telehealth or telephone visit with a provider, but those who desired kept their in-person visits. From March 23 through March 31, after a mandatory stay-at-home order went into effect, the office converted almost all visits to telehealth or telephone encounters. A physician had to approve in-person visits. Patients were given the choice of a telehealth versus a telephone encounter. Telehealth visits required downloading of a smartphone application to access a patient portal for the visit. If needed, staff assisted patients with these procedures. Virtual visits increased from 0.85% of total visits in February 2020 to 23.3% of visits in March 2020.