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.

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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

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.”

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.”

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.

“You don’t need a room to do rheum” – Canadian rheumatologists and virtual care

Canadian rheumatologists are conducting virtual visits to a significant degree during the COVID-19 pandemic but most are not using video – which many feel is the best platform for this specialty – and the majority are still not comfortable with telemedicine.

These were a couple of the conclusions that emerged from a discussion of telemedicine and virtual care at the recent annual meeting of the Canadian Rheumatology Association (CRA) framed as a “great debate”. As those who have attended annual meetings of clinical medical societies know, these debates are often positioned with amusing graphics, good-natured personal attacks, and protagonists often asked to defend positions opposite to their true beliefs.

When one cut into this particular confection there were some productive insights about virtual care and rheumatology. More came from the numerous comments posted in the associated chatroom during the debate.

In the debate, Dr. Tommy Gerschman, a pediatric rheumatologist in North Vancouver and member of the CRA telehealth working group described telemedicine as “excellent care in brand new, patient-centred packaging.” In BC, Dr. Gerschman said rheumatologists last year provided about three-quarters of their visits virtually during the pandemic period – a far higher percentage than any other specialty.

A survey by clinicians from the rheumatology division of The Ottawa Hospital and presented at the conference as a poster showed that 89% of patients said they were satisfied were satisfied with phone visits undertaken during the first 3 monhs of the COVID-19 pandemic.

In the debate, Dr. Alexandra Saltman, a Toronto rheumatologist, noted that clinicians can take a number of measurements remotely such as weight, blood pressure and swollen joint counts. She also said evidence suggests use of virtual care is not likely to miss serious diagnoses or issues when used in rheumatology.

Tasked with arguing against telemedicine, Dr. Brent Ohata, co-chair of the CRA working group on telehealth argued “we’re not ready as a community ready to provide telehealth,”. He noted that providing virtual care properly requires training, specialized knowledge, proper equipment and preparation – on the part of the patient as well as the rheumatologist.

Dr. Ohata said a survey of Canadian rheumatologists done in December found that while respondents said about 47% of their current patient appointments were being done by phone, only 19% were done using video. Even during the pandemic, the remainder (34%), were being done as in-person visits. In addition, the survey showed only 45% of rheumatologists said they were comfortable or very comfortable using telemedicine.

“The gold standard in virtual care is video,” said Jocelyne Murdoch, a Sudbury occupational therapist with advanced training in rheumatology who has been using telemedicine since 2008. In another session at the conference, Dr. Ohata agreed that rheumatologists felt they could provide better virtual care through video than over the phone.

Dr. Ohata also presented data showing that while 66% of rheumatologists indicated they could evaluate swollen joints visually, there were a number of other investigations by rheumatologists that could be done in virtual visits that were not.

Murdoch who was also asked to argue against the value of telemedicine said the supports needed to provide telemedicine in rheumatology are not yet present. She noted that in rural and remote areas many clinicians and patients do not have access to to high-speed internet connections required to do virtual video visits.

Murdoch also noted how informal many patient visits have become since the pandemic and switch to virtual visits. This issue was underscored by a number of anecdotes from participants in the virtual chat room during the debate who described patients expectations of being able to meet virtually with their rheumatology while in the most unusual circumstances.

While other physicians have also voiced similar concerns about inappropriate patient behavior during virtual visits one should note this is not all one-sided – as evidenced by the case publicized this past weekend of the surgeon who tried to contest a traffic ticket in court via Zoom, while preparing to perform surgery in the operating room.

Canada’s Virtual Care Task Force Report – One Year On

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.

Good virtual care – some principles

Is it appropriate to ask patients to be available during a 3-4 hour window for a virtual visit by a physician?  That was the question debated by some Canadian physicians on Twitter last week and it highlights the fact that many issues underpinning the optimal, ethical delivery of virtual care are still being worked out.

With the rapid expansion of virtual care due to the COVID-19 pandemic the delivery of ethical and appropriate care in a virtual format becomes even more important. This whole area been addressed in the most recent issue of the Canadian Journal of Physician Leadership by digital care pioneer Dr. Kendall Ho (@Kho8888) from the University of British Columbia, Dr. Ken Harris, deputy CEO of the Royal College of Physicians and Surgeons of Canada and Toni Leamon, a patient advocate and member of the Canadian Medical Association’s (@CMA_Docs) Patient Voice Group.

The authors note that with the growth of virtual care “it is vital that the health professional community carefully examine the quality of care being delivered digitally and determine when it is appropriate to use VC as an alternative to face-to-face care.”

“Although it is acceptable to challenge traditional thought, the use of virtual care should always be anchored on the principles that underpin the practice of medicine itself,” they add. “Modern information and communication technologies should only be considered as tools to facilitate and optimize care. Their use should benefit our patients and do no harm — a fundamental tenet of medical practice.”

The article look at principles of virtual care in 4 domains; clinical, medicolegal, adragogic, and social. What is outlined contains few surprising or contenious views.

For example, in the realm of clinical care, the article states: “judging whether to choose virtual care for health service delivery should be based on whether it is a reasonable or better option than in-person encounters in providing safe, accessible, timely, and high-quality health care to patients.”

Among the principles, the authors do include continuity of care – a factor stressed by practising physicians and one that can be lacking when virtual care is delivered outside of the usual physician-patient relationship. They write that virtual care should be considered “as time points in a continuous string of interventions in longitudinal patient journeys” and as such virtual visits should include a clear process for patient follow-up.

The article includes a lengthy section on the necessity of appropriately educating medical students about virtual care, noting that planning a curriculum would benefit from “co-creation with and participation of patients, caregivers, and communities.”

The issue of equity is also raised and the article notes that providers should be aware “not all patients have the same access to technology, because of variability and availability of resources or infrastructure in different communities and contexts.”

On the issue of how and when patients should be available for virtual interactions, the section on the principle of transparency states this should include “clear expectations about response times and ‘when the virtual office is open’.”

The authors conclude: “Tomorrow’s best practices in virtual care will certainly be different from those of today through technological innovation and evolution, and new understanding and lessons will be generated from expanding clinical applications. All stakeholders must be adaptive and flexible, as new technologies and VC approaches emerge.” 

(Image courtesy of Northern Weldarc Ltd)

The sound of tweets grows fainter

Recently I was live tweeting a major Canadian heath care conference dealing with virtual care and digital medicine when I came to the realization – not for the first time – that the most dense and lively interaction was happening elsewhere.

I usually don’t inhabit the chat forums associated with presentations on platforms such as Zoom or Microsoft Teams but in this instance I did and I found the discussion to be far denser and robust than anything occurring on Twitter using the hashtag for the meeting.

For someone who has developed somewhat of a focus on live tweeting medical and healthcare conferences this came as a revelation. Now, having attended several virtual conferences it is clear the current environment is shaping how conference materials are being disseminated.

I had already noticed that since the total transformation of major medical and health IT conferences to a virtual format that Twitter traffic around the meeting hashtags seemed sparser than usual. Not that it has disappeared, but rather than the volume in many cases is significantly reduced.

While it is great that discussion forums associated with the new virtual meeting platforms often have great engagement and are usually fundamental to promoting interactions between speakers and conferences attendees I do have a few concerns.

* Forums on virtual platforms are limited to those who are registered to a meeting or particular session, meaning comments – unlike with Twitter – are not being shared with a broader audience. The content from these discussion forums is also often immediately lost after the session has concluded.

* Discussion forums are often disabled for certain conferences – or just limited to posting questions, meaning many important medical or health conferences have no place for interaction and engagement.

* While many meeting platforms have specific functionality for people to initiate discussions on specific conference-related topics, these often seem to get little or no pickup.

* In a world where medical journalists and medical news publications are becoming endangered, the absence of any dissemination of information beyond a conference itself through live tweeting could be hamper the spread of important information and enlightened discussion about that information.

Of course, all media evolve and social media are no exception. I believe live tweeting has been an important if not essential component of medical and healthcare conferences for a few years and has shown its value. But while meetings remain virtual and take place exclusively on virtual meeting platforms I believe a fundamental shift has occurred, and this may no longer be the case.

Personally I still view Twitter as valuable in the healthcare space for both disseminating information and for networking and will continue to roost here.

But I do believe a transition to virtual meetings and whatever sort of hybrid evolves after we have braved the COVID-19 storm is going to once again transform how we disseminate and discuss ideas that matter in medicine and healthcare much as Twitter did initially and did again when the character count was doubled.

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)