On February 6th, 2020, Quality Rounds Ontario explored the promise of virtual care in Ontario. If you missed it, you can watched the archived session here.
The session reviewed the current state of virtual care, looked ahead at the changing landscape in Ontario, explored the latest evidence on keys to successful adoption of virtual care in primary care and specialty clinics, and shared patient perspectives to inform planning and change initiatives.
Below is a summary of the questions posed during the Quality Rounds. Dr. Onil Bhattacharyya, family doctor and researcher at the Institute for Health Systems Solutions and Virtual Care at Women’s College Hospital, Dr. Ilana Halperin, staff physician and quality lead for the Division of Endocrinology at University of Toronto, and Jan Gillis, patient user of virtual care provide their responses below.
What are the best resources to train and onboard patients and physicians that are interested in accessing the Virtual Visit program?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
In general, hands-on training, tailored resources, dedicated time and external implementation support to onboard patients and clinical champions who can demonstrate workflows were articulated as strategies to improve training/onboarding within Enhanced Access to Primary Care (EAPC). This will be provided by regional implementation teams and the process will vary by region. The Ontario Telemedicine Network (OTN) website has some resources.
Are there types of treatment (e.g., speech therapy, physiotherapy, and/or occupational therapy) that are currently supported by virtual care? What can other sectors learn from their experiences?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
Online Cognitive Behavioural Therapy has a strong evidence base, with a recent meta-analysis showing rapid reductions in symptoms lasting at least 6 months. See the OTN website for more information on mental health applications.
The majority of studies to date have focused on patient-physician interactions. However, preliminary findings from current field work found that involving allied health (e.g., social workers to deliver therapy treatment) may be beneficial to improve access to mental health services and integrated care (e.g., by involving care coordinators).
There may also be the opportunity to apply virtual care for preventative care, such as assessing risk factors or diagnosis screening. As Choosing Wisely suggests that annual physical exams in healthy patients are unnecessary, virtual care may offer patients a convenient opportunity for preventative counselling and screening.
Tele-rehab has been studied extensively and is widely used by private providers.
Jan Gillis:
I think Dr. Halperin was right when she said you have to pick the right patient - those that can quickly pick things up and don’t require hands on learning. If you are able to follow step-by-step instructions on how to do an exercise and don’t need the physical direction of a physiotherapist/occupational/speech therapist, I think virtual care can work. However, I think follow-up visits in person are important to ensure the therapist can go over the therapies. Then the next time can be virtual to ensure the therapy is being done properly.
What kind of work is being done to facilitate easier documentation of virtual care information into various EMR solutions?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
There are a range of solutions that are outside the EMR and send PDF reports automatically into the chart. This saves the trouble of copying and pasting, but the text is not searchable.
Virtual visits more seamlessly integrate into provider workflows when virtual visits are directly accessed from the EMR (and patient portals on the patient side) and facilitate appointment scheduling as this prevents duplicate documentation.
From your perspective, what scenarios might virtual care not be appropriate?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
The most obvious one would be where you actually need to perform a physical exam, usually for a musculoskeletal complaint. However, most of the “red flags” can be assessed on history.
New patients who have complex medical histories which are not available to the provider electronically would be more difficult to assess. Some new diagnoses would be hard to make virtually, but it would be determined on a case by case basis.
Prescribing narcotics, delivering sensitive information or bad news, and managing patients with severe mental health symptoms or addictions are also examples of when virtual care may not be appropriate.
Jan Gillis
At some time in the future when virtual care can do more than “see” and “hear,” but actually be tactile then I think that those barriers would cease.
For me, appointments with my rheumatologist are not appropriate for virtual care. He needs to “feel” my joints – are they swollen, “mushy,” or “boggy”? How flexible are they? How does my gait look? He would have to work with another person at my end for the evaluation of my joints.
Another scenario is my ophthalmologist. I complete a field vision test in his office, I get dye put into my eyes and he needs to check several things at very close range and with tools. I think with time they will come up with something within the virtual field that can mimic or replace the tools needed. I don’t believe we are there yet.
What additional tools/support is needed to scale up virtual visits in a practice?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
Invite as many patients as possible. Use administrative support to manage virtual waiting rooms for synchronous video visits. Triage visits, so that non-clinical questions go to admin, minor medical questions get handled by other clinical staff, and only questions that require a physician involvement reach the physician.
Ensure that the platform you are using allows you to easily onboard patients. Enlist clinical champions who use the technology, love it, and are influential members of their teams.
Create clear regulation/policies on documentation requirements, legal parameters of use, and guidelines on appropriate versus inappropriate use. Choose solutions that allow some degree of EMR integration.
Jan Gillis
At this point I would have to say communication. I had no idea that Women’s College Hospital did any form of virtual care until I asked. If I hadn’t asked, I would have continued my long treks to Toronto.
The more people that hear about the ability to ‘go’ virtual, the more people WILL go virtual. It works the same way for the doctors. If doctors knew of more doctors in their field going virtual and were able to see the benefit of it, I think more of them would try it.
There are many equity challenges (i.e. geography) that virtual care begins to address. From your perspective, are there any equity issues that virtual care exacerbates? How might those be mitigated?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
The ability for virtual care to mitigate or exacerbate health inequities depends on how it is implemented and the surrounding social, regulatory and policy environment. In the eVisit proof of concept pilot, providers tended to select patients with whom they had a trusting and pre-established relationship. This may mean subsets of the population who experience substantive barriers in consistent access to primary care, have poor experience/interactions within health settings and may have mistrust of the health system, and may not realize the benefits of virtual care. Further, if physicians are given free rein in terms of patient selection for virtual visits, there may be implicit biases or other factors that may cause them to disproportionately favour certain patients for virtual care over others.
Similarly, there is already a growth of private market walk-in virtual services within Ontario, requiring patients or insurers to pay a fee for access. Some studies have concluded that virtual visit users tend to be younger and situated in urban settings (re: UK Babylon evaluation). The technical requirements of virtual care (e.g., need for high-speed internet or webcam and routine access to a smartphone/computer) pose barriers to use among those with lower incomes or who are situated in rural/remote settings.
People with lower incomes and education have less ability to pay for devices and data plans. As we know that people with lower socio-economic status and education have poorer health outcomes, if we shift to a digital first model, it is likely to decrease their access to care compared to other groups. So phone and face-to-face options will remain important for certain groups.
Dr. Ilana Halperin:
The patient perspective shared at rounds revealed there are a number of concerns patients may have about connecting virtually and fear of the technology failing is significant. There is still a role for facilitated virtual visits such as in-center OTN to help manage some of these equity concerns.
Do you have any guidance for primary care groups of physicians who want to learn more and potentially to get involved?
Dr. Onil Bhattacharyya and Dr. Ilana Halperin:
OTN will be expanding the program in the near term and some regions are continuing to enroll.
See highlights of evaluation described in the OTN presentation and full report. The OTN website provides more information.