As an early partner with the MOH and OTN’s Partner Video Project, CAMH began piloting the integration of a non-OTN virtual platform for clinical use in January. We caught up with Dr. Eva Serhal, Senior Director, Virtual Mental Health and Outreach, and Dr. Allison Crawford, Associate Chief, Outreach, Virtual Mental Health, to hear more about their implementation experience across the hospital.
Last time we spoke, you were helping to inform a clinical guidance document to support the adoption and integration of virtual visits. At that time in November, CAMH was preparing for an organization-wide implementation of WebEx to support virtual care. How are things going?
ES: The implementation of virtual care across our organization has gone very well. We have gone from 300 monthly visits in February to around 6500 monthly visits in June- quite the jump!!
AC: We’ve been trying to incorporate more virtual care into our outreach programs over the last 5 years and we were very proud to have reached over 300 visits per month across 500 communities. When COVID hit, we had to adapt very quickly. Instead of 50 psychiatrists training and providing care, we have over 400. The work that we did prior to the pandemic enabled this rapid shift in care provision.
ES: We also introduced virtual care policies, guidelines, a virtual client experience survey, tip sheets, and trained over 500 staff. Additionally, we’ve published a framework on digital health equity and are using the framework to think about how we ensure a person-centred and equitable approach to virtual care throughout the organization.
What an incredible leap! How did you scale so quickly?
AC: Well we did have existing organizational policies around TeleMental health available on our website that covered different aspects of virtual care across the hospital. Having those policies and procedures in place allowed us to train staff who were going to be supporting both the administrative side and providing clinical care, quickly. We were also able to leverage training documents and experiences from the implementation of WebEx at CAMH more broadly. Because so many staff were already onboarded to WebEx for non-clinical functions, it was easier to adjust to using it clinically.
ES: It was a great example of the cross-cutting teamwork we have at CAMH, as we were fortunate enough to have a working group that included our virtual mental health team, as well as colleagues from privacy, legal, clinical leadership, information management, client experience, among other areas, that met regularly to discuss emerging questions relating to virtual care.
I read in your 2020/2021 Quality Improvement Plan that CAMH was an early partner in OTN’s Partner Video Project to pilot the integration of non-OTN virtual platforms for clinical use. What are some of the factors behind CAMH’s decision to use WebEx for video visits?
ES: The hospital was adopting Webex for corporate use, and was piloting it as part of the Partner Video Project. We had always considered the benefits of standardizing one platform for corporate and clinical usage, as we did with WebEx at CAMH. We went through a series of steps to ensure the solution met technological requirements, including those recently published in the Virtual Visit Solution Standard. New policies have made it easier for physicians to bill for virtual visits, but we wanted to avoid a scenario where all of our clinicians were choosing different platforms, and thus went through a process to scale WebEx for clinical use. Now, with existing temporary provincial policies, CAMH clinicians can use either WebEx or OTN to conduct a video visit. As part of our approach to ongoing quality improvement, we continue to look for innovations in virtual care.
What can you tell us about the hospital’s approach to implementing WebEx and how did COVID change things?
ES: We laid the foundation pre-COVID, which put us in a good position. When COVID hit, we already had an approved telemedicine policy. To get here, we took an organizational approach to implementation. We had structures in place like the virtual care round table I described above. It was a very collaborative approach. Executive leadership and champions throughout the organization were very engaged and helped support the shift to virtual care. Additionally, a lot of administrative planning was required. We did privacy assessments and developed a risk-mitigation plan to address potential risks, like what happens when you’re on a video visit and the patient needs immediate help? We also had to think through administrative processes like how to schedule a video visits vs an in-person visit and developed online training for the policy. Everything was vetted through clinical leadership and other necessary channels. We continue to review and improve upon processes to ensure that we’ve got the best virtual model possible.
What kind of guidance does CAMH provide to clinicians in terms of the kinds of patients that would benefit from virtual care?
ES: We have guidelines and policies that were vetted through our clinical leadership and quality committees that help clinicians and physicians determine eligibility; physicians are also expected to use their clinical discretion and factor in patient choice for how they would like to receive care. When you map out the process for delivering in-person care, we thought through what we need to do differently virtually. For example, when meeting with a new patient for the first time virtually, in order to confirm identity, we might ask them to show us their identification (and hold it up to the camera), similar to what they might do when they check in for an in-person visits. We also thought about safety considerations, and how it was different for virtual visits. For example, when a patient shows up for a visit, the physician will review a few key things, including a safety plan with the patient, and what to expect if the clinician is concerned for their safety.
As a result of the COVID-19 pandemic, many organizations have shifted to providing a range of virtual health care services. Why is it important to also evaluate the virtual care experience?
AC: Obviously in those first few weeks of the pandemic we didn’t want people in hospitals unless they had to be, and it was just important to find a way for people to access care. But how do we move beyond that to think about opening access and keeping the quality of care high as well? We need to ensure that access to virtual care meets client/patients where they are at, in particular those individuals and groups who experience economic, cultural or other barriers to virtual care. We also have to have high-quality care, that meets the needs of patients. We have paid a lot of attention to evaluation and quality improvement over time and one of the things to come out of this work is the Virtual Client Experience Survey (VCES), which we developed to evaluate the quality of virtual care services from a client perspective.
[To learn more about the VCES, check out this previously recorded webinar]
ES: We can also think about how the VCES situates within the broader context of measuring the success of starting virtual care. It is part of a bigger picture around evaluation and considering outcomes. The patient experience is very important but think about how you might use this information in alignment with other things, like provider readiness, organization readiness, service and health outcomes, as well as factors such as the technology, administration, and health systems.
You mentioned that you recently published a framework on digital health equity. Can you tell us about it?
ES: We published a framework on a digital health equity to ensure a person-centred and equitable approach to virtual care. It’s an evidence-based framework for systematically identifying factors that may impact digital health equity. The framework considers the social stratification process, material circumstances, and social location and the way these interact with individual factors.
AC: We have to think about barriers to care at all levels – for the individual, but also at institutional and community levels. In order to sustain the rapid shift that we have made to virtual care, while ensuring quality of care, we will now need to attend to how virtual care is integrated with other aspects of health care, and how to integrate it into communities. It is fine to recommend something on virtual care that is evidence based, but if it’s not available in the community then that starts to compound equity issues. When we’re measuring things in our programs, we have to think about who we are not serving and who we are missing. Not just measuring the people that do get virtual care, but the people who can’t access it at all.
ES: The traditional lens views virtual care as a way to increase equity. But when everyone entered the same boat and no one could access care in-person, a whole new set of considerations came up. What if you live in a dorm room and don’t have privacy? What if you don’t have a home? How can you access virtual care? Questions added to the VCES were designed to get at those equity issues.
What advice do you have for other hospitals looking to increase virtual care services for their patients?
ES: Common misconception that if you introduce a new technology or platform that people will just naturally adopt it. If you want people to use it, you need to follow an approach that includes planning and understanding key implementation factors; a team to execute the implementation including vetting and supporting technology, developing tools and training for those who will use virtual care, and user support; and a plan for evaluation including understanding of patient or client perspectives on virtual care and how their health outcomes change as a result of virtual interventions . It’s also important to listen to the feedback of your users and adapt in an agile way. If you do not partner with clinical, technology and privacy teams to support use cases, there is always risk of failure.
AC: Again, think about change not just in terms of technology, but in terms of people’s needs and strengths, and in terms of relationships. Identify people in your organization who will lead this change, and support them. Go through the process of engaging with potential stakeholders, and involve people – both staff and patients in co-designing the service. Measure your impact, and iteratively improve its quality. Also consider how virtual care will integrate with other modalities of care, such as in-person care.