A Virtual Waiting Room? Technologies That Limit Contact While Maintaining Patient Flow in Medical Practice Settings

How It Works

A virtual waiting room is an umbrella term for a variety of technologies that manage health care visits.¹ The term can be used in relation to in-person or virtual visits; however, this article will focus on the use of virtual waiting rooms for in-person visits. In this context, the term usually refers to scheduling-and-triaging software combined with some form of two-way communication between the health care workers and the individuals seeking care.

In many iterations of the virtual waiting room, an individual is instructed to wait outside of the health care facility, usually in their own vehicle, while they wait to be seen by a clinician. The purpose is to safely manage physical health care spaces. Special technology is not needed in order to contact an individual waiting in their own vehicle. However, software can automate the communication, ensure communication is safe and private, and ensure compatibility with existing software used by the medical centre for forms and scheduling.

A literature search identified 11 commercial providers of software that can be used to facilitate a virtual waiting room.^1-11 Table 1 provides a list of the 11 products or product suites identified in the search and a checklist that summarizes common features described on the commercial websites. Note that this might not be an exhaustive list of technologies and that CADTH does not endorse these products.

Who Might Benefit?

Data are insufficient to precisely define the amount of time it takes for a carrier of severe acute respiratory syndrome coronovirus 2 (SARS-CoV-2) to transmit the virus to a non-carrier; however, the risk increases with prolonged exposure.¹² The Centers for Disease Control and Prevention (CDC) guidance states 15 minutes of close exposure (2 metres or less) can be used as an operational definition of prolonged exposure; Health Canada guidance uses a similar definition.^12,13 While brief interactions are less likely to result in transmission of the virus, the type and degree of symptoms, as well as the nature of the interaction, are significant. For example, the risk of transmission increases in a brief interaction if an infected person sneezes or coughs directly into the face of the exposed individual.¹² In addition to the time of exposure, Health Canada also recommends limiting the number of people an individual comes into contact with during the COVID-19 pandemic in order to limit exposure and transmission risk.¹⁴

The primary purpose of the virtual waiting room model is to decrease the number of contacts and the total time that health care workers and individuals seeking care spend in an enclosed space together. This thereby decreases the risk of prolonged exposure to and transmission of the virus.^15,16 Both health care workers and individuals seeking care could potentially benefit from virtual waiting room technologies. There will be individuals seeking care in a medical facility who cannot participate in the virtual waiting room model for a myriad of reasons, notably a lack of access to a mobile phone or vehicle. The virtual waiting room potentially indirectly benefits these individuals by reducing the traffic in a waiting room at any given time, thereby decreasing the number of contacts and the amount of time individuals are exposed to one another in an enclosed area.

Table 1: Characteristics of Identified Virtual Waiting Room Platforms

BC = British Columbia; CA = California; EMR = electronic medical records; FL = Florida; GA = Georgia; Il = Illinois; MA = Massachusetts; NY = New York; ON = Ontario; QC = Quebec; TN – Tennessee. 
^a No information was available about this product at the time of publication

Availability in Canada

The type of software used to provide virtual waiting rooms is not a medical device that is regulated by Health Canada and therefore the availability of the various solutions in Canada is difficult to establish. However, the literature search did identify several Canadian-based companies offering these types of solutions in Canada.^7-9

What Does It Cost?

Many of the virtual waiting room services rely on individual access to a mobile phone and a vehicle. These are both expensive consumer goods and the costs are borne by individuals rather than the health care system.

Cost information for one company’s virtual waiting room software, the Chronometriq MagicSeat, is listed at US$350 per month.⁷ According to a media source, the CEO of Jellyfish Health has stated that the pricing of the company’s virtual waiting room solution would be based on a medical centre’s annual visit volumes.¹⁷

Current Practice

Guidelines released during the COVID-19 pandemic by health care organizations such as NICE–National Institute for Health and Care Excellence, the CDC, and others recommend strategies for decreasing the risk of exposure and transmission of the virus in the context of in-person health care visits in hospitals, clinics, and other medical centres. Some of the suggestions include maintaining physical distancing in waiting rooms, increasing the time between patient appointments, and cohorting patients by symptom severity.^18-23 Some guidance documents also acknowledge that patients may choose to wait in a personal vehicle or outside the health care facility, where they can be contacted by mobile phone when it is their turn to be seen by a clinician.^20-23

What Is the Evidence?

The literature search identified no clinical studies regarding a virtual waiting room model where an individual waits in their vehicle until contacted by the health care provider. However, the search identified some case reports of innovative triaging, scheduling, and waiting room practices health care facilities have implemented in order to decrease exposure and transmission risk during the COVID-19 pandemic.

A strategy reported by several types of clinics was telephone or virtual triage in advance of attendance at the clinics.^24-28 The goal of telephone triage is to determine in advance of an appointment which individuals need to be seen in person and who can be seen by telemedicine or can safely have their visit postponed. The case studies reported that the use of telephone triage reduced the number of people who needed to be seen in-person at the health care facility and therefore decreased the exposure risk in waiting rooms. This strategy is supported by a 2017 systematic review that found that patient-centred practices, including triage, reduced wait times for primary care appointments.²⁹

Safety

No evidence on the safety of virtual waiting rooms was identified in the literature search.

Issues to Consider

Health Equity

The reliance on a patient’s own resources (vehicle and/or mobile phone) makes the use of virtual waiting rooms of this design an access issue. Individuals without access to their own vehicles or mobile phones are unable to take advantage of this service. While it is possible that removing some patients from the physical waiting room does make it safer for those individuals who continue to use the physical space, more evidence is needed to support this claim. The Canadian climate varies widely by season and location. Even for those individuals who do have access to a vehicle, it may not be feasible to wait in a vehicle for an extended period during extreme weather.

Privacy

Some of the virtual waiting room solutions would be collecting and using sensitive personal health information such as a health card number or patient characteristics. The amount of information collected varies among platforms; however, platforms that incorporate additional functionality like scheduling and medical forms would likely collect more personal health information data. In Canada, it is necessary that the platforms collecting personal health information take precautions to protect data and conform to the Privacy Act, the Personal Information Protection and Electronic Documents Act (PIPEDA), as well as meet the standards set out in jurisdictional health care privacy legislation.³⁰

Related Developments

Robot Triage

A clinical trial is underway that investigates patient perspectives on robot-assisted telemedicine triage in the emergency room.³¹ The observational study aims to measure the patient response to interacting with a clinician via a robotic console in the emergency room. The clinical trial suggests that robot-assisted triage could help to prevent disease transmission to health care workers, as well as minimize the use of personal protective equipment.³¹

Patient Navigation Technologies

The literature search identified one pilot study of patient satisfaction with a hand-held device called a Mobile Patient Communicator (MPC) used to improve patient timeliness and appointment flow.³² This study found that, in a sample of 200 patients, patient acceptance of the device was fairly high.³² The MPC device is used to help individuals navigate a large health care facility without the need for an in-person escort.

Looking Ahead

Health care organizations need solutions to facilitate physical distancing and virtual waiting rooms may be a piece of the puzzle. Additional research is needed to connect the use of virtual waiting room solutions to improved patient outcomes. The use of these systems without an option for non‒technology-based options may contribute to health care inequities. However, they may still be offered at the patient’s discretion.

While the use of these solutions has expanded during the COVID-19 pandemic, they may continue to have a place in practice^15,17 — especially, like other forms of telehealth, for individuals who are immunocompromized and during times of increased risk of pathogen exposure, such as the cold and flu season.³³

Authors: Sarah Jones

References

1. The Virtual Patient Waiting Room: What it is, Why You Need it, and How to Create it. https://www2.relatient.net/virtual-waiting-room-solution/. Accessed 20200806.
2. OhMD, Inc. OhMD 2020; https://www.ohmd.com/. Accessed 2020 Jul 29.
3. Clearwave, Inc. Clearwave. 2020; https://www.clearwaveinc.com/. Accessed 2020 Jul 29.
4. Dentrix Ascend. Resource Center. 2020; https://support.dentrixascend.com. Accessed 2020 Jul 29.
5. doctible. doctible Virtual Waiting Room. 2020; https://www.doctible.com/solutions/virtual-waiting-room. Accessed 2020 Jul 29.
6. Lumeon. Lumeon. 2020; https://www.lumeon.com/. Accessed 2020 Jul 29.
7. Chronometriq. MagicSeat Queue management system. 2020; https://chronometriq.com/en/magicseat. Accessed 2020 Jul 29.
8. CareCru. Introducing The Virtual Waiting Room by CareCru. 2020; https://carecru.com/virtual-waiting-room/. Accessed 2020 Jul 29.
9. Cliniconex. Waiting room concierge. 2020; https://cliniconex.com/medical-clinics/waiting-room-concierge/. Accessed 2020 Jul 29.
10. Jellyfish Health. Virtual waiting room. 2020; https://jellyfishhealth.com/virtual-waiting-room/. Accessed 2020 Jul 29.
11. Outcome Health. Outcome Health Announces OH Virtual Waiting Room™. 2020 May 27; https://www.outcomehealth.com/news/outcome-health-announces-oh-virtual-waiting-room. Accessed 2020 Jul 29.
12. Centers for Disease Control and Prevention. Public Health Guidance for Community-Related Exposure. 2020 Jul 31; https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html. Accessed 2020 Aug 05.
13. Health Canada. Public health management of cases and contacts associated with coronavirus disease 2019 (COVID-19). Table 1. Categories of contacts by exposure risk level. 2020; https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-cases-contacts.html#fn6. Accessed 2020 Aug 12.
14. Government of Canada. Community-based measures to mitigate the spread of coronavirus disease (COVID-19) in Canada. 2020; https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/public-health-measures-mitigate-covid-19.html#_Appendix_C:_A. Accessed 2020 Aug 12.
15. OhMD. Is the Virtual Waiting Room Here to Stay? 2020; https://www.ohmd.com/virtual-waiting-room/. Accessed 2020 Aug 06.
16. Adan GH, Mitchell JW, Marson T. Epilepsy care in the COVID-19 era. Clin Med (Lond). 2020;20(4):e104-e106.
17. Cohen JK. ‘Virtual’ waiting rooms help keep patients 6 feet apart. Mod Healthc. 2020;50(25):30.
18. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. 2020; https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed 2020 Jul 28.
19. COVID-19 Guidance: Primary Care Providers in a Community Setting. Toronto (ON): Ontario Ministry of Health; 2020 May 22: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_primary_care_guidance.pdf. Accessed 2020 Jul 28.
20. National Institute for Health and Care Excellence. COVID-19 rapid guideline: children and young people who are immunocompromised. (NICE guideline NG174) 2020; https://www.nice.org.uk/guidance/ng174. Accessed 2020 Jul 28.
21. National Institute for Health and Care Excellence. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). (NICE guideline NG168) 2020; https://www.nice.org.uk/guidance/ng168. Accessed 2020 Jul 28.
22. National Institute for Health and Care Excellence. COVID-19 rapid guideline: dialysis service delivery (NICE guideline NG160) 2020; https://www.nice.org.uk/guidance/ng160. Accessed 2020 Jul 28.
23. National Institute for Health and Care Excellence. COVID-19 rapid guideline: dermatological conditions treated with drugs affecting the immune response. (NICE guideline NG169) 2020; https://www.nice.org.uk/guidance/ng169. Accessed 2020 Jul 28.
24. Cervino G, Oteri G. COVID-19 Pandemic and Telephone Triage before Attending Medical Office: Problem or Opportunity? Medicina. 2020;56(5):20.
25. Katz EG, Stensland KD, Mandeville JA, et al. Triaging Office Based Urology Procedures during the COVID-19 Pandemic. J Urol. 2020;204(1):9-10.
26. Paleri V, Hardman J, Tikka T, Bradley P, Pracy P, Kerawala C. Rapid implementation of an evidence-based remote triaging system for assessment of suspected referrals and patients with head and neck cancer on follow-up after treatment during the COVID-19 pandemic: Model for international collaboration. Head Neck. 2020;42(7):1674-1680.
27. Compton M, Soper M, Reilly B, et al. A Feasibility Study of Urgent Implementation of Cystic Fibrosis Multidisciplinary Telemedicine Clinic in the Face of COVID-19 Pandemic: Single-Center Experience. Telemedicine Journal & E Health. 2020;30:30.
28. Judson TJ, Odisho AY, Neinstein AB, et al. Rapid design and implementation of an integrated patient self-triage and self-scheduling tool for COVID-19. J Am Med Inform Assoc. 2020;27(6):860-866.
29. Ansell D, Crispo JAG, Simard B, Bjerre LM. Interventions to reduce wait times for primary care appointments: a systematic review. BMC Health Serv Res. 2017;17(1):295.
30. Office of the Privacy Commissioner of Canada. Privacy and the COVID-19 outbreak. 2020; https://www.priv.gc.ca/en/privacy-topics/health-genetic-and-other-body-information/health-emergencies/gd_covid_202003/. Accessed 2020 Aug 12.
31. Brigham and Women’s Hospital. NCT04452695: Acceptability of Telehealth Triage Using Robotic Systems in COVID-19. ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine; 2020: https://clinicaltrials.gov/ct2/show/NCT04452695?term=virtual+triage&draw=2&rank=5. Accessed 2020 Aug 05.
32. Presutti RJ, Willis FB, Scott R, Greig HE, Abu Dabrh AM. “No Waiting” in the “Waiting Room”: The Self-rooming Patient Pilot Study. Cureus. 2019;11(11):e6238.
33. Costantini R. Combat flu season with telehealth. Medical Economics. 2020 Mar 3: https://www.medicaleconomics.com/view/combat-flu-season-telehealth. Accessed 2020 Aug 14.

About This Document

Cite As: A Virtual Waiting Room? Technologies That Limit Contact While Maintaining Patient Flow in Medical Practice Settings. Ottawa: CADTH; 2020 Aug.

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