Dr. Ewan Affleck tells the story of working in Northern Canada recently and receiving a call from a panicked cardiologist in BC trying to track down a child whose holter monitor readings they had reviewed virtually. The cardiologist had identified a potentially lethal cardiac condition requiring immediate intervention but was unable to contact the child because identifying information had been removed from the chart to conform with privacy requirements.
This story graphically demonstrates the challenges faced by physicians trying to provide seamless care in the face of often perplexing policies and regulations.
Exactly a year ago, Canada’s main national medical organizations – the Canadian Medical Association (CMA), The Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada – released a task force report on virtual care (Dr. Affleck was a co-chair). The mandate of the task force was to “to develop strategies and recommendations for promoting the delivery of publicly insured medical services — by the Canadian medical community — through virtual means.”
Little more than a month later, virtual care was essentially the only way primary medical care was being delivered in Canada.
How’s that for impact.
Of course, it was COVID-19 and the necessity of avoiding direct face-to-face contact which prompted many physicians to adopt telephone and video visits in order to continue caring for their patients. As an example, a publication this week documented a 56-fold increase in the use of virtual care by primary care physicians in Ontario during the first part of the pandemic.
To support this, all provincial and territorial governments quickly adjusted their fee schedules to facilitate and remunerate virtual visits by physicians. Also, over the course of the year all three of organizations involved with the task force report provided a series of useful publications and tools to help both their members and the public adopt to the use of virtual care.
All of these moves suggest a significant shift in how health care may be delivered in Canada in the future with much talk of incorporating hybrid model where physicians and patients select the most appropriate mode for delivering care in certain circumstances be it in-person or virtual. Canadian physician leaders interviewed over the course of 2020 by the Canadian Society of Physician Leaders have been almost unanimous in identifying the delivery of virtual care as one of the most significant changes in the Canadian system both during the pandemic and post-pandemic.
On the downside, Toronto Star reporter Theresa Boyle and others have reported how private virtual health services have boomed during the pandemic a trend in direct contrast to the virtual care task force report drive to have virtual care incorporated into the public system. And to date only Alberta has made permanent the changes to its fee schedule to remunerate physicians for telephone visits.
While the federal government committed last May to spending $240 million to support virtual care, little has been done to address the more fundamental changes needed at the national level to support an infrastructure for virtual care as a regular part of delivering publicly funded medical services.
Dr Affleck’s story highlights where current privacy policies can impair the timely delivery of seamless virtual care. And as Dr. Affleck has had no hesitation in pointing out, there are other restraints that exist within the constitution of this country governing the way health care is delivered which raise barriers to delivering virtual care effectively. In his words, we are layering digital technology on top of analog policy and administration with predictable negative results. The task force report has a whole section on interoperability and governance with attached recommendations – few if any of which have been acted upon to date.
Let’s also not forget the comprehensive and often overlooked section in the task force report dealing with medical education. Of course, medical schools have been hugely challenged during the pandemic just to provide the educational necessities needed to train new doctors. So we cannot have expected much activity on needed moves to incorporate education about virtual care into all facets of medical education. But the reality exists that, as the task force noted, “virtual care must be incorporated into the medical curriculum and continuing professional development”.
The bottom line is the move to virtual care in Canada has been far swifter and more comprehensive than any on the virtual care task force could have predicted. But unless we go back and take a hard look at what that report recommends we risk enshrining the status quo and not the “best in class” virtual care that task force members and other leading physicians and patient advocates want to see.