Emily Goins

The last couple of weeks have been monumental for our project. As I wrote in my last post, prior to this week, so many questions remained – what platform could we use to conduct Telehealth appointments that would be compliant with HIPPA? How could we document the appointments without access to the paper charts at the clinic? As our appointments were previously all walk-up, and we did not have a telephone in the clinic, how were we going to contact patients and set up appointments?

This past week, we met with our lead community liaison in Fremont, one of the Chief Compliance Officers for the Duke Health System, and the Clinical Directors of the Duke Telehealth Office to figure out exactly how we could run the Telehealth system so that it would be both compliant with medicolegal requirements, and also accessible to the population we serve. Also, I, along with three other medical students on the leadership team, took a trip to Fremont last weekend to take a look at the supplies in the empty clinic, drop off cleaning materials like hand sanitizer and Clorox wipes, and investigate how we could set up a Telehealth station at the clinic.

For scheduling appointments, we will plan to create a clinic phone number using Jabber, and we will both post the number in the local poster office and ask local pastors to advertise it at services. Patients can leave voicemails at this number requesting appointments, and any one of us leaders will be able to check it. We will also gather patient’s phone numbers from the charts and call to inform them about the new version of the clinic. In order to conduct appointments, we will use a Duke hotspot and purchase two tablets. Patients will come in for 1-hour appointments and log into either Zoom (video calls) or Doximity (phone calls) to be seen by a physician and a group of first- and third-year medical students. We will have one person on-site during any clinic day to let the patient in, take vitals, and open charts to gather information on past medical history. All of our visits going forward will be documented in DukeBox.

One thing I am learning so far is that setting this up takes much more collaboration and work than expected! Since the pandemic began, Telehealth has rapidly become a comfortable format for conducting healthcare appointments. With the widespread use of encrypted Zoom, I could not imagine that there would be too many barriers to setting this up. However, ensuring that we comply with the ethics of conducting healthcare and the medicolegal regulations of a large institution, in combination with making Telehealth an accessible option for people with limited resources, is an enormous task. However, the urgency is palpable, as I suspect it may be a while before many of our patients at the clinic receive their COVID vaccine. As the COVID infection rate and death rate continue to climb, it is critical that we are able to optimize their health. We hope that the new virtual format of the clinic, in addition to providing a bridge to in-person clinic once the pandemic is well-controlled, will allow us to increase our patient population indefinitely to include those who were previously unable to make it to the original clinic every 3^rd Saturday of the month.

In addition to setting up the clinic, as we continue to prepare our first-year medical students for success when we officially begin the virtual clinic, we have been hosting educational lectures. Most recently, we had a lecture on Telehealth etiquette, including verifying patient identification, ensuring that the patient is alone in the room or that they feel comfortable speaking about medical matters in front of others who are in the room, and finding creative ways to do a physical exam (ex. having a patient press on their own abdomen to find tenderness). We also brushed up on some chronic management of diabetes and hypertension.

Emily will be working on developing a Telehealth system at a medical student-run free health clinic in Fremont, NC in order to continue to provide care to patients in the setting the COVID-19 pandemic.

The Fremont People’s Free Community Health Clinic is a student-run free clinic located in rural Fremont, NC. The clinic itself is run out of a trailer parked on a plot of grass, and it has two patient rooms, a workroom, and a waiting area. It is maintained by a board of community members. Prior to the novel coronavirus, each month, a small group of first-year medical students, third-year medical students, and one supervising physician traveled to the clinic 1.5 hours away from Durham to provide basic medical care including chronic disease management, annual physicals, prescriptions for medication refills, and basic lab tests.

Although many of the services we provide appear simple at first glance (we cannot perform life-saving surgeries or conduct imaging), this clinic serves a critical role in the Fremont community. In the town of 1,200 people, there is only one other clinic, and it is not free. Finding transportation to see doctors in neighboring towns is an enormous obstacle for most of our patients. Thus, for many, Fremont clinic is the only feasible option for receiving healthcare. Our liaisons and coordinators in Fremont relayed to us that patients were asking when the clinic would reopen so they can refill their medications, as many suffer from several chronic health conditions and feel their health deteriorating. As a medical student, I felt an incredible urge to figure out a plan so that we could get back to caring for our patients.

Initially, we worked with the DukeMed administration and the Duke Infectious Disease department to come up with a COVID-safe “outdoor clinic,” that involved a tent with some tables and chairs. This would allow us to keep most of our functions intact – we could have only clinic personnel run into the trailer to run critical lab tests, we could take walk-up appointments, and we could give flu shots. When we presented this plan to the board members of the community clinic, they told us that this would not be a feasible plan for the patients in Fremont – many would not be able to stand outside for a period of time while they waited for their appointment, and, with winter fast approaching, many thought the cold weather would turn people away. Thus, in order to be able to provide care in the setting of COVID, we have decided to shift gears from trying to find an in-person option and dedicate the winter and spring terms to creating a telehealth option for providing care.

Our project is to create a virtual, telehealth clinic in Fremont, NC in place of a clinic that was previously run entirely in person. We will run two Saturday mornings a month (8 AM-5 PM), with appointments scheduled for an hour-long period. If patients have a computer and Wifi at home, they will simply join a zoom appointment from home. If they do not have a computer or Wi-Fi at home, they will come to the clinic at the time of their appointment to log onto a computer and join the zoom call for their visit.

Some of the logistics we need to figure out are: what platform can we use to conduct Telehealth appointments to make sure that we are compliant with HIPPA?  How can we document our appointment notes so that we are compliant with HIPPA? As most of our patients were previously walk-in, how are we going to coordinate scheduling for appointments?

I think one of the things that I hope to learn through this process is how to listen and understand to community needs. One of our biggest oversights when we first set out to open up the clinic after COVID was that we had failed to ask about what the community needed, and we had created this whole detailed plan with Duke administration without realizing that it would not be a good option for the community we were trying to provide for. It was only after this failure that we stopped to ask what might work for them, and that is how we stumbled upon the Telehealth option. We will need to keep these conversations open as we navigate the waters of creating a virtual clinic for the first time.