Safety not convenience needs to guide use of virtual care: CMPA

CMPA Panel on Virtual Care

Safety not convenience should determine when to offer virtual care, according to a new white paper from the Canadian Medical Protective Association (CMPA). The CMPA document places a strong emphasis on the need for the development of clear and consistent professional and clinical guidelines and standards for delivering virtual care.

The document was released in conjunction with CMPA’s annual meeting which hosted an information panel of experts discussing the medical-legal realities of offering virtual care emerging from the COVID-19 pandemic.

In its white paper, the association called on guideline development to be done by specialty societies and by regulatory authorities who should “adopt consistent licensure requirements for virtual care delivered from another province or territory.”

“Physicians must be allowed to continue to use their professional judgment about whether virtual care is appropriate in the circumstances of each patient,” states the white paper. “However, guidelines and standards can help physicians make these decisions in a way that enhances both access to, and safety of, care and minimizes medico-legal risk.”

The report details some of the ongoing challenges with rolling out virtual care in Canada:

  • the fragmented approach across the country with respect to interprovincial licensure requirements;
  • an inconsistency in standards and guidelines for the reasonable to use virtual care;
  • lack of proper infrastructure and training about the various modalities of virtual care; and
  • lack of access to secure virtual care platforms.

While the decision when to offer virtual care rests in the hands of the physician, the CMPA also notes patient preference and autonomy should be respected.

It was CMPA CEO Dr. Lisa Calder who perhaps most accurately summarized the panel discussion and current state of virtual care in Canada in her remarks after the panel when she noted the lack of clear focus and direction for the appropriate use of virtual care.

Speakers in the panel session such as CMA President Dr. Katharine Smart and College of Physicians and Surgeons of Ontario CEO Dr. Nancy Whitmore noted the huge advances made in the use of virtual care made necessary by the COVID-19 pandemic. Dr. Smart also suggested that if regulatory hurdles could be overcome then virtual care could help address the current crisis in healthcare staffing.

“The reality is we know there’s areas that are very well resourced and areas that aren’t and and I think there’s some potential for virtual care to bridge that,” she said, “(and) I think there are also opportunities to be providing virtual supports in places that don’t necessarily have a physician.”

Cautionary notes were struck by CMPA panel representatives who noted the impact of the huge increase in the use of virtual care on the medico-legal landscape is still not clear. “I think many of us intuitively think there are risks (but) we haven’t seen the hard data to confirm that at this point in time,” said Dr. Pamela Eisener-Parsche, executive director of member experience.

“The judgment that physicians need to bring to deciding how they implement virtual care in their practices is actually different today, than it was in April or May of 2020 when many of us were in lockdown,” said Dominic Crolla, senior legal counsel for CMPA. “Although we’re in Western Canada (the CMPA meeting was being held in Vancouver), it’s not the Wild West. Virtual care, for physicians at least, has real, ethical, legal and professional standards.

Another cautionary note was struck by one physician in the audience who commented “I’m seeing virtual care being used for the convenience of physicians, and not in small ways.” However, Dr. Smart countered that when it comes to virtual care “the vast majority of people are going to do a great job and the right job and make good decisions.”

While Dr. Smart spoke enthusiastically about the positive impact of virtual care on her pediatric practice in Whitehorse it was her comment that “there is no substitution still in medicine for a good history and physical exam” that seemed to resonate most with those commenting on the session through Twitter.

Discussion during the panel also touched on the need for appropriate remuneration, the problematic nature of virtual walk-in clinics offering only episodic care, the important role of equity in delivery of virtual care services and the toll providing virtual care has taken on some physicians.

Equity and diversity addressed in new social media guidance for Ontario doctors

For the first time, Ontario physicians are being given advice by their regulatory body on how to use social media to support equity diversity and inclusiveness (EDI).

The guidance is contained in a companion document to a new policy on social media published last month by the College of Physicians and Surgeons of Ontario (CSPO). The new policy puts an emphasis on preventing conduct on social media that could harm the public’s trust in individual physicians and the profession especially the publication of misinformation.

The updated CPSO policy and companion materials show the regulatory body continues to keep pace with the current social media environment and also drops what I saw as some of the more controversial aspects that were contained in draft materials published a year ago as detailed in an earlier blog post. The reference to physicians swearing on social media as an example of disruptive behavior has been dropped. Also dropped is advice for physicians to maintain separate professional and personal accounts.

The new CPSO policy stresses the need for physicians to act professionally on social media by not posting misinformation and only posting information that is “verifiable and supported by available evidence and science.” The policy also acknowledges the important role physicians have in advocacy and states “while advocacy may sometimes lead to disagreement or conflict with others, physicians must continue to conduct themselves in a professional manner while using social media for advocacy.”

The new policy places an emphasis on protecting patient information and not sharing individual patient information without very clear, explicit consent from the patient. The policy also states physicians must refrain from seeking out a patient’s health information online without patient consent. However, the policy details several exceptions including if the information is necessary for providing health care or if accurate or complete information cannot be obtained from the patient and obtained in a timely manner.

The new section on EDI states “It is also important for physicians to be aware that their conduct on social media (including liking, sharing, or commenting on other content) may be visible to others and that unprofessional comments and behaviour (which can be overt, or more subtle, like microaggressions) have the potential to make others feel marginalized and impact their feelings of safety and trust, and potentially impact patients’ willingness to access care.” The section references cultural safety and humility and says the CPSO supports physicians “striving to foster” an inclusive environment.

The advisory document notes physicians may choose to keep professional and personal accounts on social media but acknowledges the professional and personal are not always easily separated and says it is important that physicians act professionally in both contexts.

In addition to the specific reference to advocacy in the new policy, the CSPO also addresses this at more length in the companion document. For example, it notes that “if you practise in an institutional setting, you may be subject to their policies or guidelines around social media use. Some institutions may require express permission before engaging in advocacy activities on social media that could be interpreted as directly involving them.” When advocacy efforts on social media could impair a physician’s ability to deliver quality care or collaborate with others, the CPSO says the physician should consider whether their advocacy activities “are in fact in the best interests of patients and the public.”

The College also recognizes physicians can experiencing personal attacks or harassment online due to their advocacy activities and supplies a link to a list of health and wellness resources as well as urging physicians to be aware of privacy controls and reporting mechanisms they can use.

#AI: Risks and Challenges (June 2022 edition)

Last week’s virtual e-Health conference and tradeshow featured some intriguing examples of how AI and machine learning are being used in the Canadian healthcare context – from developing a screening blood test for breast cancer to helping public health officials to manage the COVID-19 pandemic.

Perhaps more significant was a panel discussion on “practicing responsible” AI which noted that while AI has the potential to expand health services in underdeveloped regions globally, it also creates risks of creating “data poverty” by not properly including populations in the databases used to create the algorithms running clinical programs driven by AI.

A just published report by the European Parliament Panel for the Future of Science and Technology provides more of a deep-dive into the risks and ethical and societal impact of AI and machine learning touched on in the panel discussion at e-Health.

The European report was based on “a comprehensive interdisciplinary (but non-systematic) literature review and analysis of existing scientific articles, white papers, recent guidelines, governance proposals, AI studies and results, news articles and online publications.”

The report notes that “AI has progressively been developed and introduced into virtually all areas of medicine, from primary care to rare diseases, emergency medicine, biomedical research and public health. Many management aspects related to health administration (e.g. increased efficiency, quality control, fraud reduction) and policy are also expected to benefit from new AI-mediated tools.”

In the clinical setting specifically, the European report authors state the potential of AI “is enormous and ranges from the automation of diagnostic processes to therapeutic decision making and clinical research.”

The report goes on to identify and elaborate upon 7 main risks associated with the use of AI in medicine healthcare:

  • patient harm due to AI errors
  • the misuse of medical AI tools
  • bias in AI and the perpetuation of existing inequities
  • lack of transparency
  • privacy and security issues
  • gaps in accountability
  • obstacles in implementation

“Not only could these risks result in harms for the patients and citizens, but they could also reduce the level of trust in AI algorithms on the part of clinicians and society at large,” the authors state. “Hence, risk assessment, classification and management must be an integral part of the AI development, evaluation and deployment processes.”

Even with large-scale datasets with sufficient quality for training their AI technologies, the report says there are still at least three major sources of error for AI in clinical practice.

  1. Having AI predictions significantly impacted by noise in the input data during the usage of the AI tool. Eg. Scanning errors when using AI in ultrasound scanning.
  2. AI misclassifications due to dataset shift that occurs when the statistical distribution of the data used in clinical practice is shifted, even slightly, from the original distribution of the dataset used to train the AI algorithm.
  3. Predictions can be erroneous due to the difficulty of AI algorithms to adapt to unexpected changes in the environment and context in which they are applied.

The report authors outline the potential for misuse of medical AI tools and potential mitigating factors in the chart below:

From: European Parliament : Artificial Intelligence in Healthcare

When it comes to the know well demonstrated potential for bias in AI, the report suggests mitigating these risks by:

  • Systemic AI training with balanced and representative datasets
  • Involving social scientists in interdisciplinary approaches to medical AI
  • Promoting more diversity and inclusion in the field of medical AI

The report notes accountability is key to the greater acceptance of AI in the field of medicine. “…clinicians that feel that they are systematically held responsible for all AI-related medical errors – even when the algorithms are designed by other individuals or companies – are unlikely to adopt these emerging AI solutions in their day-to-day practice. Similarly, citizens and patients will lose trust if it appears to them that none of the developers or users of the AI tools can be held accountable for the harm that may be caused.” For this reason, the report authors state: There is a need for new mechanisms and frameworks to ensure adequate accountability in medical AI …”

Of course, the European report is far more comprehensive than the summary above and also provides detailed suggestions for mitigating the risks it identifies – some specific to the European policy environment and others not.

Building the health data system Canada needs (#VCAHSPR22 #Ehealth2022)

From: Expert Advisory Group Report 3: Toward a world-class health data system

Canada may be in desperate need of a world-class, person-centric health data system but the drive to implement such a system certainly isn’t making headlines … even though patients are being harmed and sometimes dying without one.

A month ago, the Pan-Canadian Expert Advisory Group (EAG) released its third and final report on developing such a system, to what can only be described as a total lack of media attention. The EAG was established in the fall of 2020 under the chairmanship of Dr. Vivek Goel with support from the Public Health Agency of Canada.

While Canadians may badly need and strongly support the set of common principles outlined in a Canadian Health Data Charter – endorsement of which was the first recommendation of the advisory group – it’s hardly a topic to knock Ukraine or even  the Ontario election of the front pages of newspapers.

However this week the EAG did have an opportunity to give a comprehensive account of its work and the issues involved at the annual meeting of the Canadian Association of Health Services and Policy Research (#CAHSPR22).

Serendipitously, the e-health 2022 Virtual Conference & Tradeshow (#ehealth2022), occurring at the same time, featured a panel discussion in which representatives from Canada’s main players in the digital health space – Canada Health Infoway, the Canadian Institutes for Health Information (CIHI) and Digital Health Canada – discussed how they were collaborating to address interoperability of health systems. As those working in digital health have know for years, interoperability is one of the key facilitators needed to overcome some of the barriers spelled out by the EAG in its reports.

As part of the EAG presentation, Eric Sutherland noted that the currently health data in Canada is “as protected as possible and as open as necessary” and a radical culture shift is required to flip this paradigm. Dr. Ewan Affleck, another member of group, made a strong case for core principles in a Data Charter to make this happen. “We have a moral obligation to do this because we are failing Canadians if we do not,” said Dr. Affleck.

While there is not space here to outline all that the EAG proposes for such a charter, the highlights include the need for:

  • Person-centric health information design to ensure that health data follow the individual across points of care to support individual, clinical, and analytical access and use.
  • The quality, security and privacy of health data to maximize benefit and reduce harm to individuals and populations.
  • Literacy regarding health data and digital methods for the public, decision-makers and the health workforce.
  • Harmonization of health data governance, oversight, and policy.
  • Support for First Nations, Inuit and Metis Nation data sovereignty.

As for implementing the strategy, the EAG calls for endorsement of the principles in the charter as a first step with other incremental advances being made towards implementation of the full strategy in a decade. The EAG also acknowledges the importance of collaboration among key players, including levels of government and the public, to bring about the strategy.

The full text of the EAG’s third report can be accessed here.

For their part the e-Health panel noted that the availability of health data in a common, standardized and structred format is the key to interoperability. Abhi Kalra, VP, Portfolio Management, Virtual Care Programs, Canada Health Infoway acknowledged, the journey to interoperability has taken some time but key organizations are now leveraging their assets and working collaboratively to bring it closer to reality.

 

 

 

Misinformation on social media threatens healthcare reform: @CMA_Docs president

Dr. Katharine Smart

Widespread dissemination of misinformation about healthcare on social media is threatening the capacity of Canadians to transform and improve how healthcare is delivered.

That is why Canadian physicians have an obligation and not an option to be active on social media platforms.

This statement was made by Canadian Medical Association (@CMA_Docs) President Dr. Katharine Smart (@KatharineSmart) at the Canadian Conference on Physician Leaders held recently in-person in Toronto. It represents one of the most high profile and strongest statements supporting physician involvement on social media made to date in Canada.

It was probably no coincidence that the #CCPL2022 hashtag was used extensively by physicians and others throughout the two-day meeting – and beyond – with both those in attendance and many others remotely commenting on and retweeting proceedings.

In her address, Dr. Smart singled out as an emerging threat to healthcare “the ineffectiveness of traditional communication tactics in a social media world, the rising threat of misinformation, a loss of trust with experts, and increasing polarization even amongst experts themselves.” She added “I think these issues threaten not only health, but pose fundamental threats to our democracy and civil discourse.”

Dr. Smart asked how physician leaders and physician organizations can compete in this new environment. “Our traditional press conferences are really no match for a well done Tiktoc video or Instagram story. Social media has become the source of information and truth for many people, youth and adults.”

“One of the lessons we’ve learned through the pandemic has been around the critical role of health communication, how much we struggled to do well, and how powerful the misinformation movement can be,” she continued.

“I think we need to recognise that social media is where we’ve evolved in terms of our community gatherings or town halls and how we distribute information and communicate with each other. If we don’t evolve and show a presence on social media to educate and impart our knowledge about health, medicine, science to the public, and even things about the health system itself, other less qualified non medical individuals will.” Dr. Smart said the CMA has made a conscious effort as part of its modernization process to become more involved and engaged on social media and has a result garners millions of impressions monly across its social media platforms.

However, with more physicians and other healthcare providers speaking out and advocating on social media, Dr. Smart acknowledged the number of personal attacks and abuse has risen. At the CCPL last year, past CMA president Dr. Gigi Osler and gun control advocate Dr. Najma Ahmed gave a workshop on just how to deal with this abuse.

Dr. Smart showed a word map demonstrating it is the most emotive words on Twitter that create the most engagement. “I believe that this is driving polarization and can negatively impact information sharing and discourse. People that are yelling are often getting the most attention and the people that actually have productive things to say … don’t always stand out in these spaces.”

She told physicians that “angry advocacy” is not the way to go and that physicians must work to counter the current “infodemic” that “threatens to disrupt and undermine our work.”

Tweets signaled COVID-19 outbreaks

Twitter and other social media platforms can serve as powerful tools to help predict outbreaks of both infectious and non-infectious diseases and should be viewed as more than just a breeding ground for misinformation.

This was recently confirmed in work by Gina Debogovich, senior director at the United Health Group and Dr. Danita Kiser (PhD) at Optum which they discussed at a session during last week’s Health Information and Management Systems Society (HIMSS) meeting in Orlando, FL.

Their assessment of several million US tweets in the early stages of the COVID-19 pandemic, showed that information contained in tweets about COVID-10 was 7-10 days ahead of public case data.

The work of Debogovich and Dr. Kiser was based on the hypothesis that “social media conversations may contain insights into COVID prevalence and may be a leading indicator for cases and hospitalization.” Debogovich said Twitter was chosen as the social media platform to evaluate because meta-data with the tweets often contains the geographic location of the tweet.

In their study, natural language process techniques were used to identify COVID-19 related tweets and classify them into different categories. Statistical analysis and machine learning was then used to determine if the tweets were leading indicators of COVID-19 spread in a community.

In their initial work,  more than 15,000 geo-located tweets that contained either an address or the latitude and longitude of the tweeter were hand classified into 7 primary categories and further divided by proximity or no proximity.

The categories used were:

  • Confirmed (the tweet stated the subject had or believe they had COVID-19)
  • Showing symptoms (the tweet indicated the subject had symptoms of COVID-19)
  • Perished (subject had died as a result of COVID-19)
  • Recovered
  • Quarantine (subject was in quarantine)
  • News (usually about a news article related to COVID-19)
  • Hoax (message contained misinformation)

Tweets were further categorized by whether they contained location data or not.

Having developed the categories, Debogovich and Dr. Kiser then assessed 100 million tweets posted from February 2020 to February 2021. They found that in the first phases of the pandemic public case data lagged tweets by 7-10 days on average. However this was reduced to 2 days in second wave of pandemic.

As a result of these findings, Debogovich and Dr. Kiser concluded that Twitter data could be useful for predicting future COVID-19 cases but the accuracy depended on the dynamics of the pandemic and tweets were most beneficial during times in which cases were rising or trending up.

Waste-water analysis and other tools are helpful in predicting infectious disease outbreaks but digital surveillance could be more effective in predicting spikes in symptoms, said Debogovich.

The study confirms early research done during Twitter’s infancy in which researchers showed how tweets could be used to predict outbreaks of influenza and other diseases. During the presentation, Debogovich said the rapid analysis of the huge amounts of data available on social media platforms remain underutilized for research and public health purposes. Mining data from social media is “hard work” and complex but could be the next big thing in predicting disease outbreaks, she concluded.

Clinicians express views on the digital future at #HIMSS22

The majority (56%) of clinicians participating in a large, global survey believe that “the majority” of their clinical decisions in the future will be made with tools using artificial intelligence (AI)

However, in the poll of about 3000 physicians and nurses conducted in 111 countries (including Canada) by Ipsos for Elsevier Health,  the majority of respondents expressed concern that medical and nursing school training was not keeping up with the need to educate them properly with the knowledge and skills needed to use modern technologies.

Findings from The Clinician of the Future study were released during the Health Information and Management Systems Society (HIMSS) annual meeting here and discussed during a sponsored session by Dr. Ian Chuang, chief medical officer for Elsevier Health.

Meanwhile results from HIMSS own State of Healthcare survey conducted at the end of last year and including 359 physicians from five countries was also releasee and discussed at the meeting. That report confirmed clinicians feel digital transformation is well underway with 90% of respondents identifying ongoing digital initiatives within their own organizations.

Interestingly, while many health system leaders polled in the HIMSS survey had reservations about the pace of digital transformation within healthcare, 16% of US clinicians said they felt their organizations had completed the transformation process and about half felt the process was well underway.

According to U.S.-based clinicians, tools that do not fit into clinical workflows, lack of proper training and lack of clear communication within the health organization are impeding transformation efforts. However, UK clinicians identified lack of clear communication as the top barrier to digital transformation.

While 88% of clinicians in the HIMSS survey reported their digital skills have improved over the past year and 79% reported choosing to use digital health tools on their own initiative, respondents in the Elsevier survey were less confident of their skills in using new digital technologies.

Of those responding to the survey, 69% feel the widspread use of digital health technology will be a challenging burden on clinician responsibilities if clinicians are not appropriately supported. In addition, 83% felt training needs to be overhauled to keep pace with intro of new technologies. Dr. Chuang said there is a sense that it is not just new information that needs to be taught but rather a shift in the whole medical education paradigm. As one US clinician quoted in the report said: “There’s no time spent separately to learn technology. That education needs to be instilled into the system to ensure all doctors are educated.”

The survey also found that 69% of clinicians globally felt overwhelmed with the current volume of data they had to deal with. While 38% of the clinicians felt receiving training and education in order to remain current will be the top educational priority over the next decade, a similar percentage believe training in the effective use of digital health technologies to assist in the delivery of patient care remotely will be the second priority

#HIMSS22 – Battling burnout with technology

Orlando, FL — Can the technological beast that has made many physician lives so miserable by drastically increasing the administrative work required to support electronic medical records be tamed and used to help reduce burnout?

That possibility was raised at several sessions here at the annual meeting of the Health Information and Management Systems Society (#HIMSS22).

The issue was first addressed in an Executive Forum held as one of a series of pre-conference symposia where speakers raised the prospect that both better analytics and the expanded use of virtual care could help with workforce retention and also in reducing burnout.

In a panel discussion, Mikki Clancy, chief digital officer at Premier Health in Ohio noted how the hospitals in her network have started using AI to reduce the administrative burden facing nurses, automating more tasks that previously had been done manually and using predictive analytics to help support more flexible working conditions. In the same discussion, Albert Marinez chief analytics officer at Intermountain Healthcare said that many clinicians have become burned out during the current pandemic and want to stop providing direct patient care in a hospital environment. For some of these physicians, he said, the broader opportunities now offered in virtual care offer an alternative which can allow them to still interact with patients in a more flexible environment.

It’s not just hospital-based physicians who are feeling more burdened today as a result of the pandemic and the requirements of maintaining electronic medical records. To quote the American Association of Family Physicians (AAFP): “The family medicine experience is based on a deeply personal physician-patient interaction that requires support from technology. But many technologies used in practice today have eroded the experience rather than enhancing it.” 

It was in part to address this that AAFP created its Innovation Laboratory  in 2018 to partner with technology companies to rigorously test new technologies such as AI and voice and mobile technologies to eliminate or decrease burnout by reducing the administrative burden on family physicians.

At a HIMSS session, Dr. Steven Waldren, VP and chief medical informatics officer at the AAFP, discussed two successful pilot projects AI Digital Assistants:

  • Suki (suki.a) is an AI-powered digital assistant that allows physicians to minimize documentation/charting time.
  • Navina (Navina.ai) integrates with the practice’s EHR and automates data aggregation and analysis to create a comprehensive patient portrait for physician review. Dr. Waldren said this tool can not only save time, it also helps ensure that no relevant information is missed.

An AAFP document states both tools “use voice recognition, natural language processing, and artificial intelligence to provide physicians with an AI assistant that continually listens, learns, and adapts to a physician’s documentation patterns and needs. The vision is for the AI assistant to be similar to a medical assistant or nurse who understands a physician’s preferences, anticipates their needs, and completes their charting for them.” 

With both of these tools, AAFP first demonstrated proof of concept with a small group of physicians and then tested the tools with groups of more than 100 practising family physicians.

With the documentation reduction tool, physicians who completed the 30 day trial saw a 72% reduction in their median documentation time per note for an estimated time saving of 3.3 hours/week. Participating physicians also expressed satisfaction with the quality of notes prepared as being more meaningful and professional. “We conclude that an AI assistant for Documentation is an

essential innovation for all family physicians who have documentation burden and experience burnout,” the report on the trial stated.

Initial results of the tool used to create patient summaries, found use of the tool reduced by 70% the time taken by a physician to prepare for a patient visit.

Numerous other sessions at HIMSS promoted a variety of technological tools and systems with the promise of helping to reduce burnout  These included:

  • APIs (Application Programming Interfaces)
  • Next-Gen Community Platforms
  • AI-optimized staffing schedulers

Cyberattack: Not “if” but “when”

“An ER doctor is on the 26th hour of her 28 hour shift and she hastily clicks on a link which she thinks will take her to an update from a patient’s family. All of a sudden her monitor is red with a black skull and crossbones flashing and a message demanding payment immediately. She looks up and sees the same message on the other monitors across the ER. Doctors and patients are starting to notice. And the ER, which is always experiencing a low level of chaos, kicks up into high gear as doctors have to work with first responders to divert patients to nearby hospitals. This is the nighmare scenario which has become all too commonplace.”

                                                 Lauren Boas Hayes describing a fictional ransomware attack

Orlando, Fl — Cybersecurity has joined interoperability as a standing theme at the world’s biggest health information technology conference – demonstrating how modern technology has now become a major threat to healthcare in addition to being a transformative asset.

Long gone are the days when ransomware and other security issues were a hypothetical threat discussed in one of the more obscure rooms at the HIMSS (the Health Information and Management Systems Society) annual convention.  At this year’s conference, cybersecurity was the topic of a full-day pre-conference symposium and had its own Command Center in the exhibit hall with several dozen companies presenting a series of talks on a variety of security issues.

Cybersecurity was similarly featured at the new ViVE22 health technology and innovation conference held the week prior to HIMSS in Miami Beach.

The issue is not just preoccupying the healthcare community in the US. In Canada, HealthcareCAN and the CIO Strategy Council announced last week that they were launching a project to develop standards to support cyber resiliency. “It is no secret that Canadian healthcare and health research institutions have proven to be popular targets for cyber attacks and the frequency of these events is only increasing, which brings an increased risk to patient care,” said Paul-Émile Cloutier, President & CEO of HealthCareCAN in announcing the project.

Despite the resources being put into combatting security threats in hospitals and healthcare systems it is clear the problem is growing and experts note physicians and others working in these organizations are still not conscious of the problem and how they can inadvertently contribute to it.

At the HIMSS conference, the organization discussed results of its 2021 cybersecurity survey which showed phishing and ransomware were the most significant security incidents reported by all types of US healthcare organizations among the 167 responding organizations.

In a news conference, Lee Kim, director of privacy and security at HIMSS, said the issue is not “if” a healthcare organization will be subject to a cyberware attack but rather “when”. With phishing being a major cause of security breaches, Kim said it made sense for organizations to have requirements with “teeth” to make sure employees follow proper procedures when dealing with emails.

While hackers are hitting healthcare systems all the time, Kim said only 78% of healthcare organizations are implementing firewalls across the board and there is not nearly enough encryption of data occurring. Security is still not being adequately funded at many hospitals and other healthcare institutions, she added

At ViVE, Lauren Boes Hayes, senior advisor for technology and innovation at the Cybersecurity and Infrastructure Security Agency (CISA) gave a brief but comprehensive presentation on the scope of the cybersecurity threat in the US and basic measures physicians could take to counter it.

“The healthcare industry and first responders have felt the disruptive impact of cyber attacks more so than any other industry over the past couple of years as the scourge of ransomware attacks has plagued healthcare systems around the world,” she said.

Hayes said healthcare organizations are particularly prone to ransomware attacks because “up time is everything” and these institutions are mostly likely to pay a ransom to regain control of their systems.

She detailed three fundamental bad practices which CISA feels can impair security.

  • Using unsupported software
  • Using default passwords or common passwords
  • Using single factor authentication especially remotely

“Investing in the technologies and teams who can implement a secure technology architecture with appropriate network segmentation, device inventories and exhaustive backups are proven to prevent catastrophic loss in the event of a successful attack,” Hayes said.

Virtual care: Not just where but how – #ViVE2022

Establishing virtual care as an accepted part of the healthcare system as a result of the COVID-19 pandemic is fundamentally changing not only where care is delivered but also how.

The implications of this for physicians and patients were discussed during a panel discussion at the ViVE 2022 conference this week in Miami Beach. While all speakers were from the US and the discussion was framed in the context of the US healthcare system much of what was said had direct relevance to Canadians.

“Pre-pandemic was mainly just telehealth,” said Carrie Nixon, managing partner in Nixon Gwilt Law and moderator of the panel discussion. “Right now, we’re in a space where virtual cares is encompassing remote patient monitoring … chronic care management services … asynchronous communication and artificial intelligence algorithms and applications.”

Commenting on the impact of changes in delivery forced on the system as a result of COVID-19, panelist Dr. Kyna Fong (PhD), CEO and co-founder of Elation Health said “not unexpectedly, there’s been a huge upswing in adoption of virtual care in independent (physician) practices. I’d say over two thirds of our clinics have incorporated virtual care into their regular everyday delivery of care for patients.”

Similar to what has happened in Canada, Dr. Fong observed that during the pandemic payment for virtual services has been on parity with delivery of in-person services for fee-for-service physicians. But she also noted that physicians using other payment models were already using virtual care and interacting asynchronously with patients.

As in Canada, where primary care physician advocates stress the value of a longtitudinal, comprehensive relationship, Dr. Fong said virtual interactions required due to the pandemic were seen in many instances to strengthen this relationship. “Some physicians would tell the story of having their first telehealth visit and finally seeing what their (the patient’s) home looks like or show them the way they kept their meds.”

Another panelist, Dr. Tania Elliot, chief medical officer for virtual care, clinical & network services, Ascension Healthcare, confirmed this beneficial aspect of virtual care. As an allergist, she said the ability to use virtual care with thousands of patients and see into the patient’s homes was “transformational”.

“For respiratory disease in particular, one of the most important things we could do for patients is understand their home environment and understand what might be triggering their respiratory symptoms. “ By doing a live walkthrough of patients homes in virtual visits or viewing the information asynchronously, Dr. Elliot said, she was able to assess ventilation, heating and other issues that can impact respiratory care and as a result better manage their condition and reduce the medications they required.

Additionally, she said, patients who were victims of domestic violence and unwilling to have an office visit were able to share their story in a way that otherwise would have been totally missed.

“I felt like telehealth really enabled me to see people living their daily lives,” said Dr. Elliot. “Telehealth is not just about access and convenience, it’s about longitudinal care delivery.”

However, Dr. Elliot acknowledged that not all physicians have had the same “eye-opening” experience with telehealth and its unrealistic to expect them to be at the same maturity level in providing virtual visits. Also – as in Canada – she said there are ongoing concerns about whether virtual visits will continue to be reimbursed adequately going forward.

Overall, Dr. Elliot said “when we’re asking physicians and practices to do more telehealth, we have to recognise that that is going to require change management and workflow related changes and perhaps interacting with different types of technologies. We have to think through the lens of the patient experience, the physician experience and the office staff experience if we’re going to expect that our physicians are now engaging in this hybrid care model (of virtual and in-person care).”

Panelist Dr. Roy Schoenberg, president and co-CEO of American Well, said one needs to appreciate the “visceral” impact telehealth can have on people by allowing them to experience care in their own environment. Another big change, he said, is that virtual care now is not just providing a channel such as the phone or video for the physician and patient to communicate but is also enabling other technologies to enhance the delivery of care.

A very important implication of this, said Dr. Schoenberg is that health care is now expanding beyond the 0.01% of the time when the patient directly interacts with the clinician in the office. With remote monitoring devices and automated technologies, he said, a much larger part of the patient’s life becomes part of the healthcare that surrounds person on an ongoing basis.

“The transition from looking at telehealth as a where healthcare happens to how health care is being rendered is the change,” he said.

On the issue of digital literacy and whether some patient populations are being disadvantaged by the growth of virtual care, Dr. Elliot cautioned against imposing one’s own perceptions and assumptions on these groups. She said data from her organization showed socially vulnerable patients from disadvantaged areas as identified by zip code used virtual care to the same degree as other populations. “We can assure these patients have access to virtual care,” she said, be it through family members, libraries or whatever.

“It’s incumbent upon us to problem solve for patients,” Dr. Elliot said. “We’ve seen 50% fewer no show rates for virtual visits than in person visits. People will figure out a way to access their doctors. We need to give them the tools to do that.”

However, panelist Dr. Geeta Nayyar, a rheumatologist and executive medical director at Salesforce stressed there was still a need to find the right balance about when to deliver care virtually and when to do it in-person. “Bladder surgery cannot be done on Zoom,” she said.

Virtual care panel at #ViVE