In the US, physicians push hard for ongoing support for virtual care

Changes instituted because of the COVID-19 pandemic that relaxed the regulatory and payment environment for virtual care appear to have strengthened the support of US physicians for the use of digital health technologies.

The survey is being used by the American Medical Association (AMA) to bolster advocacy efforts calling on the US Senate to follow the House of Representatives and continue to flexibilities around Medicare payments for telehealth and regulations supporting telehealth, until the end of 2014.  Earlier this week, dozens of US medical associations (including the AMA), academic centres and insurers also sent a letter to the Senate also urging extension of measures introduced because of COVID-19.

The situation has been mirrored somewhat in Canada where medical associations have been negotiating to extend changes in the fee schedule to support virtual care as well as advocating for regulatory changes to make it easier to offer such services.

The new survey by the AMA involving 1300 physicians shows the number who feel there is an advantage in using digital tools for patient care has risen from 85% in 2016 to 93% now. This has been accompanied by a growth in the number of doctors using virtual care from 14% to 80% over the same period.

The letter sent to the Senate states “…patients now expect and often prefer telehealth as a key component of our health care system,” said the letter, adding “virtual care is now a fundamental part of the U.S. health care system, and it will improve patient access to high quality care and strengthen continuity of care well beyond the COVID-19 pandemic.”

“Virtual care is now a fundamental part of the U.S. health care system,” the letter goes on, adding “…many of the most compelling clinical use cases for virtual care are only now emerging, more communities than ever have experienced the powerful impact telehealth has had in bridging gaps in care … without statutory certainty for remote care the hard work of building infrastructure, trust, and relationships with these communities is beginning to stall.”

Interestingly, the AMA survey indicates physicians feel improved clinical outcomes and work efficiencies rather than improved patient engagement are the main motivators for using digital health tools. In fact, the ability of digital tools to give consumers greater access to their clinical data dropped in importance between 2019 and now in the eyes of physicians as an important reason for using digital tools.

More than three-quarters of physicians polled (76%) feel that digital health tools can help reduce stress and burnout up from 69% in 2019.

The survey also shows US physicians are starting to adopt more advanced digital technologies in their practices. Eighteen percent now say they are using augmented intelligences for practice efficiencies and another 76% said they plan to do so in the future. Similarly, 18% say they are using augmented intelligence for clinical purposes with another 36% saying they are planning to do so within the next year.

Physicians will have good opportunities to view the digital health landscape in Canada this fall as both OntarioMD and Canada Health Infoway hold major conferences with updated assessments of the situation.

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.

#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.

 

 

 

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

#ViVE2022 panel addresses opioid epidemic

The new ViVE 2022 healthcare information technology conference now taking place in Miami Beach is a giddy whirlwind of delegates taking maskless selfies after surviving 2-years of COVID-19 lockdown.

This merger of meetings from the College of Health Information Management Executives (CHIME) and the HLTH digital marketplace offers fluorescent colours and images, breathless pitches from healthcare start-ups and seemingly endless repetitions of health IT’s current favourite buzz words and phrases (‘transformation’, ‘value-based care’ and ‘equity’ ranking high on the list).

But it also offers sessions where respected clinicians discuss how digital health can be brought to bear on some of North America’s most significant healthcare issues – the opioid epidemic being a prime example.

On the first day of ViVE, a panel of five experts provided an update from the front-lines on an epidemic which took 100,000 lives in the US in the last year, an increase of 28.5% over the previous year. One of the panelists, Dr. Scott Weiner, chief of health policy and public health at Brigham and Women’s Hospital, Boston noted the number of overdoses associated with opioids has risen over the last two years even though the number opioids being prescribed has actually dropped significantly – pointing to the impact of the COVID-19 pandemic – and mental health issues associated with being isolated.

While acknowledging the role fentanyl and the illicit supply of synethic opioids is currently playing in the pandemic, much of the presentation at ViVE focused on how digital health is helping encourage and monitor appropriate prescribing in acute-care settings post-surgery.

Patricia Lavely, VP and Chief Information and Digital Officer in the Health District of Palm Beach County, described reported results from a CHIME survey of these opioid-use reduction technologies and strategies.

The results from 2021 showed that:

  • 100% of organizations had electronic prescribing of controlled substances
  • 92% had order set maintenance to offer non-opioid options
  • 90% had an eprescribing modules connected to the State or regional Prescription Drug Monitoring Program (PDMP)

Other data from the survey showed organizations reported that this eprescribing connectivity had the highest impact on opioid-use reduction. It was also noted that CHIME has an Opioid Task Force to offer resources for its members but many hospitals were not yet taking advantage of all the health IT tools available and doing all the “easy things” they could do to help deal with this issue.

Lavely said despite the use of technology and electronic health records, opioid overdose deaths continue to rise at a “horrific pace” and that much more needs to be done to identify at-risk patients and those with an opioid use disorder.

Panelist Dr. Matt Sullivan, chief information officer at Atrium Health, noted that while health informatics specialists have huge amounts of data on patients in association with opioid use more needs to be done to analyze and share what can be learned from this information.

A discussion of existing patient risk scores concluded their usefulness was limited because they depend on patients giving honest answers and also fail to take into account many other variables besides prescription drug use associated with the risk of having a substance use disorder.

Panelists acknowledged the importance of harm reduction and especially the use of naloxone to reduce opioid deaths and also said more must be done in healthcare institutions to reduce the stigma against drug use.

“One thing we can take away from this session (on the opioid epidemic) is that harm reduction and naloxone will save lives,” said Dr. Sean Kelly, chief medical officer of WELL Heath and moderator of the session.

It was acknowledged at the start of the session that many patients need adequate pain relief and may fail to obtain it. But as panelist Dr. Greg Polston, chief informaticist and associate medical director UC San Diego Health noted more than once, misprescribing opioids is something that can lead to a clinician losing their license.

Overall it was noted that while clinicians and those working in health IT are doing a lot to help deal with the opioid epidemic more can be done even though many of the variables involved remain out of their control.

Opioid Panel at ViVE 2022

Against for-profit virtual care: @FamPhysCan makes the continuity of care case

One of the cornerstones of primary care medicine in Canada is continuity of care and the idea that care offered by the same family practice over the lifetime of the patient is the ideal state.

Continuity of care is also seen by primary care advocates as one of the most compelling arguments against having virtual health care services offered by for-profit private companies.

This case was recently made most explicitly by the College of Family Physicians of Canada (CFPC) in a Feb. 22 report titled: Buying Access Will Cost You: The Unintended Consequences of For-Profit Virtual Care.

The report is a direct attempt to counter the recent significant growth of for-profit virtual care in Canada. An evaluation of virtual care in Canada by CADTH published in June, 2021 listed 12 private companies offering a variety of virtual care services in Canada with most being paid on individual basis although some services are covered by private insurance or public health plans.

The CFPC report is also a followup to a CFPC policy statement “Strengthening Health Care – Access Done Right” published in August, 2021 which stressed the need for “access to high-quality, comprehensive, continuous primary care close to home …” That document implicitly questioned the growth of private companies providing intermittent virtual services detached from the relationship between patients and their family physicians.

In the new report and an accompaying news release, the CFPC detailed how the organization feels paid-access virtual care is inferior to continuous, patient-centred care which has “a host of benefits for patients including greater quality of life, better health outcomes, and lower rates of emergency department use.”

“Episodic for-profit care also jeopardizes patients’ continuity of care,” says the report. “Patients using episodic virtual care are less likely to regularly visit their family doctor. Further, providers working through for-profit solutions often do not have access to a patient’s full health record and they generally do not share information with the patient’s regular care provider to maintain continuity.”

The report cites a report from the Ontario Auditor General’s office which found patients using for-profit virtual care are less likely to be regularly seeing their family physician and that this demonstrates a lack of continuity.

The importance of using virtual care to support continuity of care with an established provider rather than for-profit services was also tacitly endorsed in the second Virtual Care Task Force report prepared by the Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada as well as the CFPC.

Interestingly, Maple – one of Canada’s leading for-profit virtual care companies – also recently strongly endorsed the concept of continuity of care and that organization’s commitment to the idea.

“Continuity of care is a crucial component of effective healthcare, and in a virtual setting, the consistency and quality of care that a person receives as they transition between care settings is more seamless than ever,” stated Maple in a blog published Oct. 21.

The blog goes on to talk about informational and management continuity and argues that Maple supports both:

“Informational continuity is delivered through access to a patient’s medical history, by both the patient and provider, in order to give complete informative care via shared or electronic health records. This enables providers to view the patient’s history and build on previous treatment and diagnosis. In a virtual setting such as Maple, access to consistent patient record-keeping ensures comprehensive care during every single visit.

“Coordination of care across multiple providers, which adapts to needs over time, is defined as management continuity. Any healthcare provider interacting with the patient can collaborate with others involved, both in a virtual setting and the physical world. As more patients turn to virtual care to complement in person care, it’s important that they have control over their documentation and that’s why we’ve built in a secure medical records feature,” says Christy Prada, vice president of business development at Maple.

The blog does not address the pivotal concern of the College of Family Physicians of Canada that private companies such as Maple who offer virtual care interrupt or impede the continuity of care offered by family physicians. The CFPC statement also does not deal with the issue of the million plus Canadians who do not have a regular family physician and are thereby denied the benefits of continuity of care by a regular primary care provider – and the niche private virtual care companies could or should fill in helping give these patients the care they need. While CFPC acknowledged in their report that “for-profit virtual care services, such as virtual walk-in clinics, have acted as a stop-gap measure to improve access to care for some” it added that  “in doing so (they) present serious risks to the health care system.”