Virtual Care in Canada: An update from organized medicine

The COVID-19 pandemic has catapulted virtual care into the mainstream of healthcare delivery but there is still “much work” to be done to establish high quality virtual care as an integral part of the publicly funded Canadian healthcare landscape.

That’s the conclusion from representatives from Canada’s three main medical organizations – the Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada working in conjunction with patient representatives to produce the just-released Virtual Care Task Force (VCTF) report.

Acknowledging that virtual care has not benefitted everyone equally during the pandemic, the report’s authors also emphasize the need to make equity a foundational principle for the delivery of virtual care going forward.

The report is the second from the VCTF which released its first report exactly two years ago, the same day the World Health Organization put a name to COVID-19. At that time, virtual visits by telephone, text or video formed only a small portion of how care was delivered despite the capacity to do so having been in place for some time.

As the second report documents, the COVID-19 pandemic drastically changed the situation. With the imperative to offer physically distanced care in order to protect both patients and physicians, the report shows how fee structures were amended almost overnight in all Canadian jurisdictions to encourage physicians to offer care virtually. The report quotes a number of Canadian surveys showing the dramatic increase in the number of virtual visits as well as generally high levels of patient and physician satisfaction with virtual care.

The report goes on to trace how the “virtual first” philosophy in 2020 evolved over the following months to the extent that by the fall of 2021, governments and regulatory bodies were urging physicians to offer more in-person care and to gauge when it was appropriate to offer virtual care. The report also shows just how much effort has been invested by the federal government and a number of other organizations in the last two years to assess and recommend how to best provide virtual care.

As with preparation of the first report, the task force created subcommittees and considered virtual care from four perspectives; interoperability and governance, licensure and quality of care, payment models and medical education.

In addition to stressing the need for equity, recommendations in the new report call for:

  • Ensuring that appropriate virtual care services are funded as part of the publicly funded health care system.
  • Promoting guidance for providers and patients on the appropriate use of virtual care
  • Having governments and medical associations work together so
    • physicians are paid at the same rate whether care is provided virtually on in-person
    • there is support for an appropriate balance of both in-person and virtual care
    • payment is made for virtual care services provided asynchronously via secure email/text messaging

Recommendations in the initial report called for the need for a framework for pan-Canadian governance of virtual care and the need for medical regulators to establish standards to support “competent and safe virtual care” and these were reaffirmed in the new report. On the issue of governance, the report notes there continues to be a need for “the adoption of true patient co-design in developing a virtual care governance model as a standard of being”.

However, the task force notes, pan-Canadian licensure for physicians, which is seen by many as a necessity to allow doctors to provide virtual care across provincial borders, is no closer than it was two years ago. “While development of a pan-Canadian medical licence remains of high interest to many, little concrete action has been taken in advancing this initiative since the release of the initial VCTF report,” says the report. “In fact, when it comes to virtual care, some regulatory authorities have strengthened their requirements that physicians must be licensed in their jurisdiction to offer care to patients in that jurisdiction.”

In addition while governments were quick to allow physicians to bill appropriately for virtual care, the report notes these changes to fee schedules have only been made permanent in one jurisdiction to date.

The report concludes by stating:

While events since February 2020 have done much to advance many of the recommendations made by the VCTF and its working groups, incorporating virtual care optimally into the Canadian health sector requires more work on the part of the federal/provincial/territorial governments and national organizations. Specifically, there is a need for universally endorsed principles of virtual care design and deployment, and an aligned virtual care governance and policy approach across all jurisdictions.

The report’s authors also finish with a warning about the continued growth of private companies offering virtual care services outside of the publicly funded health care system and state this requires urgent attention. “This trend is just one of several issues that must be addressed to ensure that virtualized services improve access while maintaining safe and equitable service — something that the VCTF feels is currently lacking.”

The VCTF was co-chaired by Drs. Ewan Affleck, Kenneth Harris and Gigi Osler. Task force membership included representatives from many medical organizations as well as patient representatives.

Beyond Jimmy Buffett: The New Medical Conference

The new reality of medical conferences shaped by the COVID-19 pandemic requires not only a new language but also a fundamental rethink to make these major showcases of medical organizations and societies a place where physicians and patients can share their experiences and perspectives.

We can no longer characterize medical conferences as – in the words of an old Jimmy Buffet tune – “a Holiday Inn full of surgeons” who meet there every year and “exchange physician stories and get drunk on Tuborg beer.”

That is the unavoidable conclusion to be drawn from a webcast held earlier this week featuring Len Starnes, a Berlin-based digital healthcare consultant and close observer in medical conference trends. The webcast is part of a regular series hosted by Peter Llewellyn for MedComms Networking.

A year ago, Starnes presented to the same webinar series and outlined how the COVID-19 pandemic had caused most medical conferences to become virtual in nature. Then, he predicted all medical conferences hosted by associations or societies would be held virtually until at least the last quarter of 2021. In reality, few if any major medical conferences were in-person only 2021 due to the ongoing pandemic and this trend is now extending into 2022.

The new reality – which dominated much of the current webinar discussion – focused on the ascendance of “hybrid” medical conferences featuring a combination of in-person and virtual components. With physicians having discovered the benefits of virtual meetings and now wanting a choice in how they experience conferences, this approach that allowing both synchronous and asynchronous learning is here to stay.

One of the major features of the new medical conference, said Starnes, is that they now feature “more opportunity” for including patients and “could be a radical breakthrough for patients and patient organizations.”

Despite patients having had a presence on the agendas of some medical conferences for more than a decade and the formal Patients Included movement putting its stamp of approval of medical meetings since the mid-2010s, what we may be seeing is a more fundamental shift.

“Basically now, there’s no more discussion about the value patients bring,” said Starnes.”It looks like we may be moving into a new area of patient participation.”

“Patients and patient organizations have told me it is important (to acknowledge) patients are not just there to listen, they are also there to present. They can present their experiences of being on a drug … or whatever it is and explain to doctors what it means, for them. Patient organizations say it’s very important that doctors understand what they’re doing from a patient perspective.”

In the webcast, Starnes was joined by Ilan Ben Ezri, CEO of G-Med, a social physician-only community with 1.5 million members from more than 160 countries. A survey of 1206 physicians from countries conducted by G-Med in 2021 showed an even split between preferences for in-person, virtual or hybrid medical meetings with the preference for in-person meetings being greatest in the youngest (aged 20-40) group of physicians.

In discussing the future of medical conferences, Ben Ezri implied the drive for patient-inclusion may get pushback from physicians who still want to discuss their study findings in a peer to peer environment.

However, Starnes noted there is a counter-view that “excluding patients is not really appropriate”. He cited a European Medicines Agency statement that input of real world patient data is “absolutely crucial.” The opportunity to share perspectives in order to support the paradigm shift to shared-decision making is something health care “can’t avoid,” he said.

Another fundamental challenge to the more active participation of patients at medical conferences is a regulatory one that can restrict physicians from reporting data from new drug trials to audiences that include non-physicians. However, Ben Ezri pointed out the fluid nature of the new hybrid medical conference could get around this by creating some sessions restricted only to physicians (although patient groups could well argue that it would be much more appropriate to change the regulations concerning reporting of pharmaceutical data).

Cost is another issue. Medical conferences saw attendance skyrocket early in the pandemic when there was no registration fees and patients benefitted from this. But with medical societies facing the necessity of having to reinstate often hefty registration fees to cover costs, many patients or patient organizations with no financial backers may once again be left in the cold.

And let’s not forget equity and the reality that may patients who should be in the room at a conference to present their unique perspectives may have neither the time or capability to attend – although here again the virtual option may present new opportunities.

Many questions indeed but those witnessing the dominant social media participation of the Creaky Joints arthritis patient community at last fall’s American College of Rheumatology meeting or IBD Moms at last month’s Crohn’s and Colitis Congress are seeing how this new future looks.

A full recording of the webcast with Starnes and Ben Ezri can be accessed here.