Virtual Rounding: Using Technology to Support Inpatient Providers and Facilitate Medical Education
Late last March, beds at the Brigham began to fill with COVID-19 patients and many trainee educational programs were disrupted. As the pandemic grew, Nora Becker, MD, PhD, a Brigham resident at the time, was eager to find ways that trainees and other clinicians could support teammates remotely. In search of innovative, digital solutions, she asked if she could join in on rounds on an iPad. This idea kick-started the Brigham’s Virtual Team Rounding Program (VTRP).
Together with Narath Carlile, MD, MPH, the director of innovation for the Brigham’s Internal Medicine Residency Program, Becker helped co-found the VTRP, which has enabled many residents, fellows and fourth-year medical students to remotely learn from and support providers caring for COVID-19 patients. In addition, physicians and physician assistants from multiple specialty groups, including dermatology, radiology and radiation oncology, were able to quickly train and provide support to inpatient clinical teams.
“I really wanted to help,” said Becker. “I didn’t like staying home while all of my co-residents were working hard to take care of COVID patients. As a senior resident, I could write notes, discharge summaries, review patient histories, and place orders. There was a lot of stuff I could do. Once we saw that people at home could easily help the team, we began to see the potential for the model.”
Today, medical education at the Brigham has resumed a familiar look, with medical students, residents and other trainees accompanying physicians in-person on rounds to patient rooms. But the lessons learned during the height of the pandemic could help optimize rounds in the future, especially if new surges occur.
A Team Effort
As the number of COVID cases rose dramatically last spring, providers were thinly stretched. Due to personal protective equipment shortages and efforts made to control the spread of the virus, the hospital began limiting the number of people that could enter patient rooms. The virtual rounding program enabled hospital staff to safely support their colleagues from home and provided students and residents a way to continue their education. Becker and colleagues quickly recruited students, trainees and faculty across specialties to participate in virtual rounding.
Providers working on inpatient COVID-19 units brought virtual rounders with them on iPads. The iPads were set up in or right outside patient rooms, sometimes taped to IV poles for easy transport. Virtual rounders assisted with daily notes, discharge summaries and documentation, lifting some of the weight off of their colleagues’ shoulders and fostering educational efforts.
Implementing VTRP required mass collaboration between departments across the Brigham. Hospital leadership stepped forward and lent the team the staff and support needed to build the program.
Word of VTRP spread quickly throughout the hospital. People from departments across the Brigham offered their time and assistance. The Brigham Virtual Care and IS teams volunteered to be on call, troubleshoot technology issues and deliver devices to program participants. Specialists from departments like Radiology and Dermatology, who had fewer patients due to the cancellation of many outpatient services, volunteered to serve as virtual rounders to providers working with COVID-19 patients.
“It was a special time because everyone was really motivated to make it work and be helpful in any way that they could, said Becker, “Because it was such a huge disruption of everybody’s routine, people were more open to just experimenting.”
A broad range of health care providers offered to be virtual rounders. Thirty-nine participants, including 16 residents, five fellows, six attendings, six physician assistants and six fourth-year medical students, rounded for 24 in-patient teams for the program’s duration.
Virtual Rounding participants — both those who joined in virtually and those physically at the hospital — had positive things to say about the program.
Herrick “Cricket” Fisher, MD, a hospitalist at the Brigham and director of the Integrated Teaching Unit, began working every other week on COVID direct-care hospitalist teams in March of 2020.
“The Virtual Rounding Program dramatically decreased my administrative burden, which was critically important to lighten the load,” said Fisher. “It saved me about two hours per day of time that I would otherwise have spent at the computer, typing up information that I had already reviewed or things I had already performed.”
“It was like a magic trick where my in-person interactions and out-loud thoughts flowed onto the page effortlessly. I was still doing all the thinking and reviewing I normally would, I just didn’t have to also write down everything that I already experienced.”
While clinicians founded VTRP to address the gaps in care created by COVID-19, many aspects of the program also increased patient access to medical services and supported patient well-being.
During virtual rounding, participants found that having iPads inside patient rooms enabled family members that were not allowed inside the hospital due to COVID restrictions to speak one-on-one with their loved ones. Adam Licurse, MD, executive director of Virtual Care, noted that although many people already have smartphones to communicate in such a way, many others do not. Placing devices like iPads in hospital rooms allows those without access to such technology to communicate with family outside of the hospital.
“From a health equity perspective, not every patient comes into the hospital with the technology needed to communicate with friends and family members,” said Licurse. “These tools provide a lifeline in those situations.”
Notably, such technology also enabled bilingual providers to tune in to rounding teams treating non-English-speaking patients. Mallika Mendu, MD, MBA, executive medical director of clinical operations, a physician at the Brigham and a co-founder of the VRTP who oversaw the operations of the program, says that this is an aspect of the program she hopes continues moving forward.
“Having bilingual providers connect with patients in their language was an unanticipated benefit of virtual rounding,” said Mendu.
Medical Education Going Forward
While the virtual rounding program provided enormous benefits to students and providers during the COVID-19 pandemic, Licurse emphasizes that technology cannot replace certain aspects of patient care.
“iPads don’t allow you to examine patients with your hands and your stethoscope. They don’t allow you to communicate via body language or understand someone else’s body language in the same way. A lot of the bedside manner and companionship that happens between trainees and mentors has just been lost.”
Although many providers and students have returned to in-person rounding, there are aspects of the virtual rounding program that they hope to carry into their practices when the pandemic subsides.
“Using this technology at a systems-level — at a large academic medical center with multiple campuses — allows for shadowing, observation, exposure and communication to occur over long distances without any of the logistical challenges that may have existed in the past. I do think these tools allow for medical education to occur more seamlessly,” said Licurse.
Mendu conveyed that the pandemic pushed her and her colleagues to think innovatively. They plan to carry over aspects of this program well into post-pandemic medical education.
“COVID forced us to think about how we use technology effectively and creatively in a way that medicine has not pushed itself to do before. We need to embrace the technology moving forward and acknowledge that there are some real benefits.”