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Virtual Waiting Room
Share PrintIncrease in use of telehealth during the pandemic dramatically expanded provision of virtual care, and the ease and convenience of virtual appointments has ensure this modality is here to stay. However, virtual appointments lacked a formalized real-time check-out process, including scheduling of the next appointment, which has led to delays in scheduling follow-up appointments and some veterans being lost to follow-up. We developed and implemented the Virtual Waiting Room (VWR) to address this.
Origin:
April 2021, Pittsburgh VA Medical Center-University Drive
Adoptions:
2 successful, 10 in-progress
Awards and Recognition:
Diffusion of Excellence Promising Practice, VHA Shark Tank Winner
Recent Updates
Overview
Problem
Multiple staff members and vet ... Increase in use of telehealth during the pandemic has dramatically expanded provision of virtual care. However, virtual appointments lack a real-time check-out process, including scheduling of the next appointment, which has led to delays in scheduling follow-up appointments and some veterans being lost to follow-up.
Multiple staff members and veterans expressed frustration with difficulty asynchronously scheduling follow-up appointments outside of virtual appointments. An increased time to complete return to clinic orders was observed, as well as an increased number of return to clinic orders that were never completed. See more
Solution
- Virtual Waiting Room SOP, with the Pittsburgh Specific details (e.g. phone number, individual's names) removed. SOP
Files
Results
Our psychiatrists also comment that use of the virtual waiting room seems to improve the frequency (and ease) with which veterans are rescheduled in the clinically indicated time-frame. "It helps me do my work in that I have fewer pending return to clinic orders and can schedule acute cases easily." Further, psychiatrists report the frequency they do not receive links to VVC appointments has also been reduced with the VWR.
Due to the success of the pilot program within the Behavioral Health Service Line for VAPHS, implementation of the Virtual Waiting Room was made a "Just Do It!" Action Item for VISN 4 (for either PACT or behavioral health) as of April 2024.
Separately, staff at VA Fresno developed a similar process integrated within their BHIP staffing. Per their staff, "Fresno BHIP teams have been testing the use of Virtual Check Out in order to ensure timely access and streamlined path for Veterans to receive follow up care, improve Veteran satisfaction, improve work efficiencies for schedulers, and reduce the amount of administrative work in making repeated contact attempts to schedule appointments after visits have ended. We have tested the process with 2 BHIP teams thus far with plans to roll out further. In our process, the provider alerts the AMSA that the appointment has ended, RTC order is entered, and Veteran is ready to be scheduled. The AMSA joins the Veteran in the VMR at the end of the visit in order to complete scheduling. In our first team to implement the process, 72% of RTCs were successfully scheduled during virtual check out. Providers and AMSAs all reported satisfaction and excitement with the process and asked to be able to continue it past the testing phase." Dr. Kathryn Connolly is their program manager and has been the laison between Fresno and Pittsburgh in sharing our success with these very similar processes. See more
Metrics
- Since implementing the Virtual Waiting Room, we have observed a reduction in open return to clinic orders. Anecdotally, our psychiatrists report that scheduling is completed quicker and more accurately (veterans are seen closer to the clinically indicated date), though we are still working to obtain the metrics to prove this. We have also compiled data demonstrating lower no-show rates as well as improved productivity among outpatient psychiatrists utilizing the virtual waiting room compared to peers not yet utilizing our innovation.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
VVC encounters, VVC wRVUs, and No-Show Rates between psychiatric staff utilizing VWR and those who were not. Comparison of number of VVC encounters, VVC wRVUs, and no-show rate between psychiatric staff using the Virtual Waiting Room and those who were not.
The above chart demonstrates that use of the Virtual Waiting Room (VWR) in VA Video Connect (VVC) clinics results in return to clinic orders being closed (and thus follow-up appointments scheduled) much more rapidly than for VVC clinics not using the Virtual Waiting Room. With use of the Virtual Waiting Room, these metrics are nearly equivalent to those of in-person clinics!
For one of our psychiatrists who joined the Virtual Waiting Room midway through it’s piloting, we were able to compare data demonstrating that use of the virtual waiting room reduced the gap from the clinically indicated return to clinic date and when the patient was actually able to be seen next, on average, by 6 whole days! Impressively, the % of patients who were scheduled on or before the desired date improved by nearly 30%! While the overall time past desired date of 10.4 days remains higher than desired, we believe this was confounded by factors not related to the Virtual Waiting Room itself, including understaffing (both of psychiatrists and MSA staff), veterans who were not able to stay connected via VVC (and either converted to telephone after partially completing the appointment, had to use a video platform other than VVC and the MSA was not able to join the video, or who had to leave the virtual appointment before the MSA could join for one of a number of reasons. Many of these veterans were then not able to be reached by the MSA (and/or did not call in themselves to schedule as requested by the psychiatrist). This would be akin to a patient who was in a rush and left an in-person appointment before checking out with the front desk staff; we believe this occurs at nearly comparable rates.
Implementation
Timeline
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1-6+ months
Step 1: Staffing. Implementation of the virtual waiting room requires at least one MSA as well as practicing clinicians. Transitioning current staff into this role would enable the process to be implemented faster. The upper bound of the time represents hiring a new, separate physician to see virtual patients. -
1 week
Step 2: Training. Staff would need to be familiarized with VVC and scheduling software, as well as complete relevant general and telehealth TMS trainings. This may also be shortened by using staff already familiar with the relevant programs. -
0-3 weeks
Step 3: Equipment. Represents estimated time to acquire a GFE laptop and softphone for virtual employees. This could again be reduced by staffing VWR with current VHA staff who already possess the necessary equipment for their current duties.
Departments
- Education and training
- Telehealth
- Information technology
- Human resources
Core Resources
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Risks and mitigations
| Risk | Mitigation |
|---|---|
| 1) Missed Opportunities/Clinician Time. Unfortunately, there is often a gap between when the clinician finishes the encounter and when the MSA is able to enter the room. If the clinician leaves the room during this time, there is a risk that the veteran will also leave the room before the MSA is able to connect. Remaining in the room to prevent these missed opportunities places a burden on clinician time, with the potential for negatively impacting productivity. | To mitigate this, we have recommended that clinicians mute their microphones and complete documentation tasks while awaiting the MSA to enter the room. The psychiatrists who have implemented this practice have found it very effective in ensuring the veterans remain in the room with minimal negative impact on their overall ability to complete their daily tasks. |
| 2) Inadequate technology. Virtual Waiting Room requires use of VA Video Connect (or equivalent program), which requires all staff and veterans to have adequate technological resources, including a video-capable device with a web camera and microphone and adequate internet connection/bandwith. If a veteran does not have the necessary devices, there may be some cost to the VA to provide them with a loaned iPad or similar, such as through a VA Digital Divide consult. Of note, this risk is inherent to virtual care in general, and not specific to the virtual waiting room. | As above, this risk is inherent to virtual care in general. Adoption of the virtual waiting room would not be expected to significantly increase costs to the implementing facility beyond what is already incurred for providing virtual care. |
| 3) Inadequate Staff. Our process is dependent on having adequate MSA staff to be available to schedule veterans at the time their virtual visit is concluding. If the veteran has to wait an extended period of time for MSA staff to enter the VVC room for scheduling, often times veteran will disconnect, particularly if the provider has also already left the room (such as to avoid delaying the start of their next clinical encounter). | To address this, we designated a specific MSA to respond to the virtual waiting room scheduling requests, freeing them of other MSA tasks. Efforts to have one MSA address both virtual and in-person check-out simultaneously have generally not been successful. We have tied our expansion of the program to additional clinicians based on the number of MSAs we are able to dedicate to the Virtual Waiting Room. |
About
Origin story
Original team
Steven R Graham, MD
Behavioral Health Telemental Health Champion / Point of Contact / Outpatient Psychiatrist
Sophia Monsour, DO
PCMHI Psychiatrist
Amita Mehta, MD
Treatment Resistant Depression Section Chief
Jordan Harris
MSA Supervisor
Melanie Ponist
Virtual Waiting Room MSA
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