Two-tiered texting: Do virtual visits spell an end to medicare

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Arguably the most significant plenary session at this year’s recently concluded #ehealth2019 conference in Toronto was a panel discussion on the impact of virtual primary care visits on continuity of care.

The panel featured Dr. Ed Brown (@DrEdMBrown), the CEO of the Ontario Telemedicine Network (OTN), Dr. Brett Belchetz (@Brettbel), founder and CEO of Maple, the country’s largest private provider of virtual care, and Dr. Monika Dutt (@Monika_Dutt), a family and public health physician and an outspoken advocate for social justice.

Among the dozens of presentations at the conference co-sponsored by Digital Health Canada, Canada Health Infoway and the Canadian Institute for Health Information this presentation shone the brightest  light on the core issue facing the growth of digital care in Canada – how can the demand and interest in such an approach be accommodated within a publicly funded health care system already overwhelmed by financial demands?

One answer that seems clear is that the demand to be able to text a family physician at any time and receive an answer within minutes is so attractive that those with money or 3rd party insurance can and will pay to do so – thereby creating the two-tiered system, based on ability to pay, which has always been so adamantly avoided by the Canadian psyche.

The growth of Maple shows just how this demand is big and is growing. Dr. Belchetz noted that when Maple started in 2014 only one quarter of one percent of physician visits in Canada were done virtually. Now, he says, Maple has a network of 400 family physicians across the country with 350,000 patients paying for “almost instantaneous” access to care.

Dr. Brown noted the interest in this approach was confirmed by both patients and providers in a pilot conducted by OTN in five regions of Ontario  involving 277 providers and 33,000 patients. That pilot showed overwhelming support for the approach and he noted 90% of the interactions were resolved through secure messaging and did not require in-person follow-up.

“Basically, people just want to be able to text their doctor,” Dr. Brown said adding that the pilot documented very little overuse or abuse of the approach by patients.

While acknowledging the benefits of virtual care especially in rural and remote areas, Dr. Dutt noted virtual primary care must be integrated into the comprehensive, integrated and publicly funded primary care system or else it risks creating inequities between those who can and cannot pay privately for the service.

British Columbia is currently the only jurisdiction in Canada that provides funding for family physicians to interact virtually with patients. And, as Dr. Belchetz noted, this is confined to video visits while he said what patients really want is the ability to text with their physician.

The interest and demand for virtual primary care is so great, Dr. Belchetz said that other provinces are “terrified” to fund it because of the financial demands it will place on already overburdened systems.

Drs. Belchetz and Brown said it will be important to be able to demonstrate that virtual primary care provides value for money and can be delivered in a cost-effective manner in order for provincial governments to agree to put it into the fee schedule for physicians.

Dr. Belchetz also made the point that instantaneous virtual access to a family physician means a person with a non-urgent or self-limiting condition – he used the example of an itchy toe – might be inclined to contact a physician about it whereas if an in-person visit was required then they probably wouldn’t bother. He said there needs to be a way of triaging or gating access, so such frivolous demands do not overwhelm the system.

Today that is done in Canada by requiring payment to access systems such as Maple – a two-tier system based on ability to pay if you will.

Should virtual access to a family physician become an essential requirement for health care in the 21st century – as many think it is fast becoming  – absent any effective method of making this affordable it arguably spells the end to equitable access to care as we know it.

One EMR to rule them all: The @HQOntario #HQOchat

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Recently, Health Quality Ontario hosted a lively and informative tweet chat (#HQOchat) on integrated care – and again and again the need for a shareable electronic source of patient information was mentioned as key enabler.

The chat featured a distinguished panel of moderators: Health Quality Ontario VP of Quality Improvement Lee Fairclough (@lfairclo), patient advocate Annette McKinnon (@anetto), University Health Network President and CEO Dr. Kevin Smith (@KevinSmithUHN) and Marathon, ON family physician Dr. Sarah Newbery (@snewbery1). With more than 100 participants, the discussion was wide-ranging and focused on what is already being done and what could be done better to integrate the care patients receive in Ontario.

The importance of a unifying electronic medical record (EMR) or source of patient information to allow patients and providers to better manage care and help ensure the seamless transition in care across different environments was raised repeatedly.

Those who have been following discussions about EMR and health technology over the last couple of decades will recognize this as a riff on the old theme of interoperability and the need for EMRs and other systems housing patient data to be able to communicate better with each other.

“Today it seems so possible, and (it’s) time to put focus on digital solutions to support integration,” was how one participant put it. Asked what integrated care meant to them, another responded “from a patient’s perspective, the whole team knows what it’s going on – there’s no need to repeat that story / circumstance over and over again,” to which a physician responded: “(we) need a way to have easy digital transitions of this info.”

In response to a question about what was needed to build a fully integrated health care system, Health Quality Ontario Interim President and CEO @annagreenbergON answered in part “patient and caregiver access to their own records. EHR. Virtual care.” Another participant answered: “A fully integrated system is 1 inspired by patients & caregiver needs, as articulated by them. Patients & caregivers are fully involved co-designers of that system. There is single portal where all medical data are held, synchronously accessible by patient & doctor.”

On the flipside, the lack of accessible electronic patient information was identified as a barrier to integrated care.

“ …. who can take lead in shepherding all providers into using common EHR (electronic health record) framework? It’s tragic that even hospitals across from each other can’t share easily. We also block innovative private partners who are lost/blocked from plugging into a standardized network,” one physician wrote in a post.

“…we don’t have access to our primary care records and even access to hospital records and lab results is uncommon. So, we need access to more info,” @anetto posted.

Another doctor tweeted: “I think the genie has already left the bottle to consider a single EMR – need instead to focus on joining up the info out there – Connecting Ontario is probably the best option to build on!”

“We need multiple options to access and share information,” stated one post.

And this post put some context to the discussion: “A province wide record would definitely be helpful, but I think it’s more than that. The technical solutions are important, but we also need to be mindful of things like relationships, good communication, & having time/skills to collaborate.”