Primary Care: A 30 minute drive away but virtual options also needed

Having the right to a relationship with a primary-care team within 30 minutes of home or work is the main recommendation coming from the first major Canadian health policy paper to be published this year.

But while stressing geographic proximity to primary care, the Public Policy Forum document “Taking Back Health Care” is noteworthy for its emphasis on the need to incorporate virtual care into care delivery in a reformed and modernized healthcare system..

The report and its recommendations also merit attention because of the prestigious list of physicians which includes; Dr. Jane Philpott, dean of health sciences at Queen’s University; Dr. Vivek Goel, president and vice-chancellor, University of Waterloo; Dr. Alika Lafontaine, president of the Canadian Medical Association and; Dr. Bob Bell, former Ontario deputy minister of health.

The document notes that during the COVID-19 pandemic there was a “rapid, positive shift” in how Canadians accessed health services. “Video visits, phone calls, online engagement (including the use of bots and automation to support online interactions), remote monitoring, etc., quickly ramped up to support care when being in person was not safe,” the report continues.

While use of these virtual tools had both advantages and drawbacks, the authors state “we cannot rely solely on in-person access in a modernized, effective health system.”

“We need to put virtual into the continuum of care in a way that reinforces patient relationships with care providers, based on a clear understanding of when it is appropriate to use it and when it is not. It is on our system leaders and providers to ensure virtual care is integrated, convenient, of high quality, AND equitable.”

In addition to referencing the need to integrate virtual care, the report also talks about the importance of people having the ability to access their health data. “Empowering individuals with their data includes the ability to seamlessly and securely share information within that individual’s circle of care and for that individual to have an integrated health record that follows and is tied to them,” the authors write.

Noting that health data often currently exists in siloes, the report emphasizes the need to make health information available to providers and policy makers while first addressing “legitimate” data governance and privacy issues. The Pan-Canadian Health Data Strategy is identified as a roadmap to how this can be accomplished.

The Public Policy Forum paper is one of a series that will be published this year as part of the Future of Health Care Project.

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Continuity of care trumps instant access to virtual care: Poll

Canadians like the convenience of having instant access to virtual care through virtual “walk-in” clinics but the majority place a higher value on having an established relationship with their own primary care physician.

That’s one of the conclusion that can be drawn from findings of a new poll by Ipsos conducted on behalf of the Canadian Medical Association.

The study focused specifically on the perceived value of the continuity of care that is a cornerstone of the traditional doctor-patient relationship between primary care physicians and patients in Canada. This continuity of care was also the focus of a recent report by the College of Family Physicians of Canada which was highly critical of for-profit virtual care.

The online Ipsos poll of 2,000 Canadians was conducted conducted between September 14-23, 2021.

It found that 81% of respondents agreed it is important to have an ongoing relationship with a family doctor who understands their changing needs, while 79% agree it is important to have an ongoing relationship with a family doctor who understands them as a person.

Asked whether they placed a higher priority on an ongoing relationship with a family doctor or team or on having care that was more convenient, 59% of those polled favoured the ongoing relationship while 33% gave equal importance to continuity of care and convenience.

Asked about virtual walk-in clinics where patients can receive care by phone, video or other means when they want it, only 9% of respondents placed the value of this service above having an ongoing relationship with a family doctor. However about a third of those polled said they are less concerned about having an ongoing relationship with one family doctor, if the doctors and health care providers providing their care had electronic access to their health records.

Of the 36% of Canadians who said they had used a virtual walk-in clinic, 48% said the experience was positive – a rating that falls below the 59% of who report an overall positive experience with a family physician. While only 28% of all those surveyed said they would consider using a walk-in clinic, 40% said they would be more likely to use a virtual walk-in clinic than a family physician for minor illnesses or injuries or for prescription refills. The same percentage said they would trust a doctor in a virtual walk-in if they did not have an established relationship with a family doctor.

Despite the problematic findings about virtual walk-in clinics in this poll, other findings confirm how virtual care is becoming a standard feature of medical care in Canada since the COVID-19 pandemic began. Six in 10 of those surveyed said they were aware their family doctor offers virtual services, an increase from before the pandemic when only 12% knew their family physician offered this service. In addition, more than half (54%) said it was very/somewhat important to them that their family doctor offer virtual services.

While the telephone remains both the preferred means and actual way in which patients access virtual services, the survey did find the percentages of patients wanting to communicate by either video, email or text were significantly higher than what their physician currently offered.

Based on the findings in the survey and more in-depth conversations with a smaller group, Ipsos concluded that “continuity of care is important for the majority of Canadians … but virtual episodic care has a role to play in providing more timely access to health care and it is seen as somewhat overdue in today’s digital world.”

#PrimaryCare2025 vision calls for better connectivity

Connected care through a better integrated digital health infrastructure in Ontario is a key part of the vision for a reformed healthcare system outlined this week in a white paper released by a group of primary care leaders.

Primary Care 2025 lays out a roadmap for health care in the province based on inter-disciplinary primary care hubs where providers would have responsibility for geographically defined populations. Linking primary care to all other aspects of care in the community would be facilitated by “an inter-operable electronic medical record (EMR).”

In discussing how care has been provided during the COVID-19 pandemic, the study authors note that the lack of shared EMR created a challenge of data access. “While adoption of electronic medical records in Ontario ranges, many physicians are still using EMRs in the same fashion in which they used paper records: as a standalone patient record accessible only to the family physician in that practice,” the report states.

“(A) robust cross-platform referral management modules would help coordinate referrals to eliminate costs or delays to care while helping to coordinate diagnostic workups to avoid repetitive and unnecessary testing. A shared database enables communication among providers as well as supporting systematic sharing of best practices. The economies of scale can be significant.”

The report goes on to say that implementing an EMR that contained both health and social care data by 2025 “would provide more seamless care for patients who require care by multiple sectors, facilitating collaboration between the primary care provider and providers working in home, community, mental health and addictions care.

The study authors point to a particular issue in Ontario with the separation of public health labs from primary care EMRs. “The inability to understand risk for a whole population for which primary care has a shared responsibility is a challenge that must be overcome in a post pandemic era. This is one example of the need to strengthen the connection between primary care and public health.”

The report as calls for the ability of all providers including those providing homecare to be able to communicate via instant messaging. “In the pre-pandemic era, most Ontarians did not have access to virtual care via phone or video appointment. Only small numbers of Ontario patients were able to communicate via email with their primary care team.” The report also contains a number of other recommendations intended to reform the system from medical education to more consideration of the social determinants of health

Virtual care: Signposts along the way

Virtual care has been propelled to near the top of the health care communications agenda by the #COVID19 pandemic. It’s now hard to avoid podcasts, articles and webinars dealing with the way the delivery of care has embraced virtual platforms in the face of the need for physical distancing between physicians and patients.

I have touched on this in earlier posts and will continue to do so, especially with the #ehealth2020 conference coming up in 12 days and @CMPAmembers selecting this as the topic for their annual meeting focus in August.

But in the interim, and at the risk of being accused of missing more seminal markers of where we are going in the virtual space I want to quickly offer up the following snapshots:

1. Early in the year, Canada’s most prominent medical organizations (@CMA_DOCS, @Royal_College and @FamPhysCan) prophetically produced a virtual care task force report laying down a series of recommendations needed to integrate virtual care into the health mainstream. They have subsequently followed up with polling data backing the use of virtual care and are now heavily promoting a patient guide on how to navigate a patient visit. This is an unprecedented endorsement of the use of virtual platforms in Canada. The guide states that virtual care is a way for patients and physicians to continue to work together “to achieve the best health outcomes possible.”
2. The Canadian Society of Physician Leaders (@CSPLeaders) has been hosting a series of podcasts dealing with how physician leaders have been approaching the #COVID19 pandemic and lessons learned. It is interesting that many of the 19 people interviewed to date have focused on the adoption of virtual care as one of the more significant changes in the health care system as a result of the pandemic. Many of these physicians have also predicted that the ways in which virtual platforms are being used will permanently change how health care is delivered in Canada. In fact, comments about virtual care were so pervasive that CSPL turned them into a specific podcast.

To quote from a couple of the interviews:

• I think this pandemic has given us a very tangible use case for virtual care that we are aggressively exploring … across the country. I think we will come out of this years ahead of where we might have been in terms of the clarity around how we can use virtual care for follow up and for primary care …:  Dr. Brendan Carr, president and CEO of the Nova Scotia Health Authority
• Prior to the pandemic, I would say that less than 1% of our consultations were being done virtually. And now that … it’s become an imperative that we reduce the risk of infection, I imagine that rate has jumped to maybe 40% of consultations being done via telemedicine. In many cases, we aren’t going to be going back, because we’re realising that there are many advantages to virtual care: For example, monitoring patients at home, and perhaps pre screening patients to determine whether or not it’s wise for them to come into the emergency: Dr. Philip Edgcumbe, a young physician innovator.

3. Earlier this week, @BMJ_Open published the definitive version of a pilot project involving the use of virtual care in five regions in Ontario and involving 326 primary care providers and 14,291 registered patients in rostered practices. Results from the retrospective cohort study have been reported earlier but not in this peer-reviewed context.

Described as the largest evaluation of virtual care within primary care in Canada, the study looked at both video and secure messaging on digital platforms provided through the Ontario Telemedicine Network, and patient and provider preferences for each.

Key findings from the retrospective analysis included:

• 99% of patients indicating they would use virtual care services again
• Physicians and patients showed a preference for secure messaging over video visits.
• Providers indicated that 81% of virtual visits required no follow-up for that issue

The authors concluded that “despite fears that virtual visits would be overused by patients, when patients connected with their own primary care provider, many virtual visits appeared to replace in-person visits, and patients did not overwhelm physicians with requests. This approach may improve access and continuity in primary care.”

4. The Centre for Addiction and Mental Health (@CAMHNews) – which has seen virtual visits grow 850% in March and April has just hosted a podcast discussing virtual care with @DavidGratzer and Dr. Jay Shore, chair of the American Psychiatric Association’s Telepsychiatry Committee. While psychiatry is often identified as one of the specialists best suited for the virtual delivery of care, the discussion also referenced challenges such as the digital divide and inequities in access to virtual services.

To quote Dr. Gratzer “everyone right now is getting virtual care for the most part because we don’t have an alternative. This isn’t a true system it’s an accidental happenstance system, so to speak.”

In the podcast, Dr. Shore also talked about the concept of hybrid care where physicians and patients interact in a variety of ways in the post-COVID world. “I have relationships with people in person, over video, over telephone, texting, patient portals, social networking. And so it’s understanding how to use the technologies to form good, strong relationships for clinical care, trying to understand which technology to use with which patient and when.”

As noted the above are just a small selection of the ongoing discussion about virtual care and its role in a post-COVID19 world in Canada.

Stay tuned.

( Photo of Hungarian Pavilion, La Biennale di Venezia, 2017)

 

Better, but not there yet: Use of IT in primary care in Canada

When it comes to the use of information technology in primary care in Canada the best that can be said is that all the numbers have trended in the right direction since 2015.

Released by the Canadian Institutes of Health Information (CIHI) last week, the 2019 version of the Commonwealth Fund International Health Policy survey of 11 developed countries focused on primary care physicians and contains a wealth of data on the use of technology as well as on access and coordination of care.

At a time when Canadians and especially primary care physicians are engaged intense discussions about how to better use digital technology to improve care and better involve patients, what is most striking about some of the Commonwealth Fund findings is just how far many Canadian jurisdictions are from even having the basic tools to do this.

While the survey confirms the fact that overall Canadian primary care physicians have made huge gains in incorporating electronic medical records into their practices in the last decade (kudos to @Infoway and all the money put into enabling this in the 2000s), these gains are not evenly distributed. And when it comes to the use of health IT, Canada continues to lag behind other countries polled, in many instances badly.

While 86% of Canadian primary care physicians overall report using electronic medical records (EMRs), the 2019 survey shows only 1 in 4 (26%) are using EMRs in PEI while that percentage is 61% for primary care doctors in New Brunswick and Newfoundland.

Of course, the absence of an EMR makes any electronic engagement with patients or use of information technology to improve quality care a moot point.

As for providing patients with electronic access to their records or enabling electronic communication, Canada continues to also lag most other nations surveyed. Only 23% of Canadian primary care docs offered the option to ask medical questions via email or a secure website, and only 5% have the capacity to let patients see summaries of their medical record online.

These numbers fell far below the average among the other 11 Commonwealth Fund countries surveyed , which includes Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K. and the U.S.

We are also falling short when it comes to connectivity between physicians: The survey showed only 25% of Canadian family doctors used EMRs to exchange clinical summaries and 36% to exchange laboratory results with other physicians (Commonwealth Fund averages: 63% and 65%, respectively).

So, some good stats when looks at 2015 numbers provided for comparison, but many miles to go.

(Illustration: Cover of Future Practice magazine published by the Canadian Medical Association, May 2011)

 

 

 

 

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

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 3^rd 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 21^st 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.