Virtual Hospital

If the COVID-19 pandemic has taught us anything, it's that the vast majority of the population can be served, for health and safety reasons, virtually and online.  

NAMD is now in the planning stages of creating a "free clinic" to transition into a "virtual hospital" in the next few years.  After this pandemic has cleared, hopefully soon, we'll begin work on the new "virtual hospital".

It's purpose is to serve the general population through catastrophes such as the COVID-19 Pandemic.  It will be a volunteer academic hospital for doctors and will operate as a "free clinic" to serve the general population. 

We've been approached by humanitarian groups and other non-profits that want to assist us, and see the need as urgent.  We're presently working with start-ups that have new touchless technology that can be useful.  We look forward to it's completion and your involvement.



Telemedicine is the practice of healthcare whereby one physician will reach out to a single patient in his/her home or the clinic and discuss healthcare matters. Telemedicine is not new; it has been around for the better part of a few decades. Physicians have been practicing telemedicine by advising patients on health matters over the phone and computers all over the nation. At the same time, the practice of telemedicine was a privilege granted to a few physicians. But with the COVID outbreak, the concept has been expanded to include Virtual Healthcare. With a Virtual Hospital, there is a whole team of physicians in different specialties who manage the patient in one setting. The physicians usually work out from a central call center (or clinic) that is fully equipped with all types of electronic technology to help access the patient across geographical borders. Unlike telemedicine which is a one-stop deal, a virtual hospital encounter is similar to what takes place in a live hospital arena. The patient is continuously followed by a team of providers - the only thing missing is the physical presence of the patient.
First, a virtual hospital allows the physician to obtain a complete history. In addition, today there are all types of apps available that can help physicians monitor vital signs, and even access patient’s own medical devices like the glucose meter, blood pressure, pulse oximeter, weight scale, and laboratory reports, and of course, EPIC. Once the patient data has been acquired they are stored on a cloud platform so that they can be accessed by any physician by signing into the system. This way, all providers who follow the patient can continuously monitor the patient. Virtual hospitals provide quality care to the patient from the comforts of a localized setting- either the home, ICU, nursing home, or any other remote destination. The other key advantage of virtual hospitals is that it eliminates distance, travel, language, and money. The system bridges the access gap that is so common in the real world between physicians and patients. With a virtual hospital, physicians can be accessed 24/7 by the patient.
With the introduction of new technology in healthcare, the role of the physician has also become virtual. Physicians no longer have to be physically present at the patient bedside and monitor vital signs every shift or assist the clinician during clinical rounds. From a central location, the virtual physician can visit as many as 2 patients every hour. Also, specialized physicians can provide extra support for general nurses looking after complex patients. Virtual hospitals now allow for rural patients to remain in smaller hospitals with minimal facilities and yet have full monitoring by a physician. This not only saves money but avoids the long transport time and inconvenience of traveling to tertiary care facilities.
When employed as a virtual physician, responsibility may include the following:

- Provide telehealth services to patients
- Diagnose patients
- Determine whether patients should receive lab tests
- Determine the level of treatment and care they should receive
- Monitor patient vital signs using electronic technology
- Know how to interact electronically with other healthcare professionals when troubleshooting
- Give patients advice on healthcare matters and when they should seek medical care
- Process insurance claims
- Triage online patients
- Operate a call center

First and foremost, safety for the physician and the ability to triage patients. Virtual healthcare is here to stay and this branch of medicine now offers physicians added specialization in digital analytics. Virtual physicians can oversee virtual nurses. Virtual physicians will be frontline workers and a source of referral to other specialists.

Medicine has always been a physically demanding job, but with virtual care, this may help ease the physical demands. It is anticipated that virtual nursing will help reduce physician turnover and increase compensation.

The physician's central workstation will usually have several large monitors with split screens connected to the patient monitors. The main computer may also be linked to EPIC or other software for patient’s medical records. The high definition cameras even allow for the virtual physician to read the settings on the monitors. The virtual physician's workstation allows for the management of many patients at the same time. For example, in the past when a bedridden patient was wheeled to the radiology suite, a whole team of healthcare workers had to accompany the patient. Now with virtual monitoring, just one or two individuals are necessary as the patient can be monitored from a central location. With virtual monitoring, there is no longer a need for a physician to remain with most patients.
To become a virtual physician means first becoming creditials and having a state license. Secondly, the physician must have some familiarity with virtual technology. At the moment, to become a virtual physician, some states do require that physicians complete classes in computer science and electronic technology. Because virtual medicine is a new discipline, physicians may be asked to create protocols and guidelines for other physicians to follow. Hence, one may need to spend 1-2 years developing computing skills so that one can make a remote diagnosis and advise patients without physically examining them.
Yes, a physicians can prescribe from a virtual hospital.
The virtual hospital should generally be used by patients with non-emergency conditions. Or to refer them to the ED if it is an emergency condition. For example, if a patient has a traumatic injury or is suspected of having appendicitis, then the individual should be referred to the nearest emergency room to be seen by the on-call ED physician. There are several other surgical scenarios for which a virtual hospital is not recommended. For example, if the patient is suspected of having a breast mass, then a thorough physical exam is warranted and in this case, a visit to the clinician’s office is recommended. For the most part, a virtual hospital is ideal for people with chronic disorders.
Yes, when a patient calls to make an appointment with a virtual hospital, he or she will have personal details taken and asked why they want to see a physician. The triage nurse will then determine if the patient is suitable to be seen by the virtual health care team or needs a referral to a physical facility for a more in-depth examination.
Yes, because physicians and nurses are all stationed at a remote central location, they can all observe the patient from a central screen and ask questions for more detail. The patient, in turn, can also ask any questions to the specialist. To avoid repetitive online meetings, an attempt is made to manage the patient in one sitting, if possible. And of course, there's always Epic.
Yes, with today’s technology a patient in an ICU setting from anywhere can be accessed by the virtual hospital as long as there are audio and video facilities where the patient is located. The system also allows the physician to access the patient’s monitoring equipment data in the ICU and make recommendations to the physician on call. The physician can monitor the patient’s vital signs 24/7 and send out alerts to the monitoring team if there are issues.

Today the potential of virtual hospitals is endless. The availability of high definition video and two way communication allows the system to be used in the following situations:

- Monitor patients at home
- Monitor infants in hospital and at home
- Manage emergency units
- Observe post-operative patients at any location. This is of growing importance as many patients are now discharged home the same day after surgery. The virtual hospital can now monitor the patients in their home
- Monitor elderly in nursing homes for falls
- Monitor the safety of patients in mental healthcare institutions
- Monitor critically ill patients in rural areas who are not able to visit tertiary care centers
- Follow patients with chronic disorders

Today, technology has allowed for the creation of miniaturized electronic accessories that can be connected with Bluetooth. These devices include wearables like bracelets, Holter monitors, wristwatches, blood pressure cuffs, glucose meters- all of which can then be monitored by the virtual hospital team. These devices keep track of the patient's daily movements, activities, and automatically trigger an alarm if something is aberrant. For example, if the glucose machine records low blood sugar, this will sound an alarm that will alert the virtual team who can then take action.
  1. Virtual hospitals allow for an extra pair of eyes with vast monitoring capabilities. Physician's can assess a patient’s home condition without even going to the residence. The system allows for better connectivity with patients with hopefully long term benefits.
  2. The virtual hospital has removed many physical barriers. The system is of the greatest benefit to patients living in parts where access to healthcare is not available. By using currently available technology and expertise of better-trained healthcare workers, virtual hospitals offer improved healthcare across geographical boundaries.
  3. A virtual hospital helps connect patients in secluded areas of the nation where there are no healthcare specialists. In addition, a large number of patients today have limited mobility and others may not have sufficient funds to make the long journey to tertiary care centers. Thus, virtual hospitals may turn out to be a cost-effective option for these populations
  4. For patients with chronic disorders like diabetes, COPD, cancer, congestive heart failure, arthritis, or coronary artery disease, it can be a real struggle to physically come to the hospital to be seen by a clinician. Now virtual hospitals can make a difference. Because of the possibility of remote monitoring, patients with chronic disorders can minimize the number of real-time visits and instead have their checkup done by a virtual team. This reduces time, costs, and the aggravation of travel. The savings can be real for patients who do not have to make long journeys.
  5. A virtual hospital means patients do not have to sit for hours in the waiting room to be seen by a physician there are no delays seeing a specialist because the virtual team already has specialists on board. There is no need to continuously rebook or cancel appointments for whatever reason.
  6. Finally and very important, virtual healthcare helps decrease the spread of infections that are so common in real-life hospitals. Not only does it eliminate the spread of injection from the patient to the physician but also to other patients.

For the most part, Telemedicine is not routine practice and only a few select institutions and healthcare providers have been granted permission to conduct healthcare in this manner. To date telemedicine has been approved by a few states and allows clinicians to attend to the medical needs of patients living in rural areas. For the most part, almost every state has laws that discourage the practice of Telehealth and the same applies to Virtual Healthcare delivery.

The Health Resources and Services Administration (HRSA) of the Dept of Health and Human Services defines telehealth as the use of electronic information and telecommunication technologies to support and promote long-distance healthcare, patient and professional health-related education, and public health administration. Technologies include the internet, video conferencing, webinars, live streaming, use of the landline, and wireless communications. In addition, both Medicare and Medicaid also have certain restrictions on the types of technologies that can be used as part of telehealth. The use of telehealth services is rigidly controlled and enforced by the Office of Civil Rights. And the penalties for those who disregard HIPAA are severe.

However, with the recent COVID 19 pandemic, the rules of telehealth have been relaxed and the covered healthcare providers will not be subject to penalties for violations of HIPAA as long as the rules are obeyed in good faith. Healthcare providers and healthcare institutions have the onus of ensuring adequate security and safety of all medical information during telehealth delivery-there is no exception to this rule; it is mandatory. Further, before undertaking delivery of telehealth, all healthcare workers who partake in this activity must be fully aware of HIPAA rules and be up to date with the latest information on the topic.

At present, telehealth is permitted because of the COVID-19 crisis but when this Notification of Enforcement Discretion will expire is not known. The Office of Civil Rights will issue a notice to the public when it is no longer exercising its enforcement discretion based on the latest facts regarding COVID 19.

In the meantime, physicians are expected to conduct telehealth in private settings like a clinic or an office with a patient who is at home or in another clinic. It is absolutely forbidden to receive or transmit telehealth services in a public or semipublic setting unless there are exigent circumstances. If telehealth cannot be provided in a private setting, the provider should implement reasonable HIPAA safeguards to limit disclosure of protected health information (PHI).

Some examples of what OCR may consider a bad faith provision of telehealth services that is not covered by this Notice include: Conduct or furtherance of a criminal act, such as fraud, identity theft, and intentional invasion of privacy; Further uses or disclosures of patient data transmitted during a telehealth communication that are prohibited by the HIPAA Privacy Rule (e.g., sale of the data, or use of the data for marketing without authorization); Violations of state licensing laws or professional ethical standards that result in disciplinary actions related to the treatment offered or provided via telehealth (i.e., based on documented findings of a health care licensing or professional ethics board); or Use of public-facing remote communication products, such as TikTok, Facebook Live, Twitch, or a public chat room, which OCR has identified in the Notification as unacceptable forms of remote communication for telehealth because they are designed to be open to the public or allow wide or indiscriminate access to the communication.

All physicians should be familiar with their own platforms and not use other platforms for telehealth.

As long as the telehealth communication is done in good faith during the COVID outbreak and even if there is a disclosure of PHI to a third party, OCR will not impose a penalty for HIPAA violation but the agency will consider all facts and circumstances before making a decision. The provider needs to discuss with the patient the limitations of electronic technology and the potential for disclosure despite adequate safeguards. The patient must agree to this before telehealth services can take place.

Before undertaking telehealth or the practice of virtual medicine, it is important to speak to the Administrative Dept as to how to conduct Telehealth. Penalties for violating HIPAA are expensive and can ruin a healthcare institution’s and the physician's reputation.

Final point

In the USA, many hospitals are now adopting virtual hospital technology as this has become a necessity since the COVID pandemic. Patients, in fact, also prefer this type of medicine. But at the same time, there is a demand for more computer-savvy physicians- making a diagnosis virtually is not always easy. Plus, physicians need to know the limits of virtual care. But for many physicians who are computer literate, this may be a great specialty as it is less physically demanding and satisfying but on the other hand, requires broader medical and computing knowledge.