September 2, 2021 – by Justin Hall – In late 2020 and early 2021, several hospitals implemented “virtual ED” programs as COVID-19 cases increasingly strained and threatened to overwhelm the healthcare system. You may be wondering what virtual care really is, and why it is becoming so prevalent in Canada. You may also wonder if this is a program that can be of benefit in your practice.
In this month’s HiQuiPs post, we will introduce virtual care, its perceived need, and establish a foundation for a series that will comprehensively dissect virtual care within the healthcare space, particularly as it relates to the ED.
Virtual care – what is it?
According to the CMA Virtual Care in Canada discussion paper,1 digital health and virtual care can be described by the following principles:
- Integration of electronic health data and analytics.
- Use of audio, video, and other technologies to deliver preventive, diagnostic, and treatment services.
- A tool that promotes patient and population health.
Digital health and virtual care offer another dimension in the patient-provider interaction. Importantly, virtual care is not a replacement for in person care; instead, it aims to support and enhance quality of patient care.
Virtual care is yields significant promise for improving how and where medicine is practised, but also comes with potential risks. While virtual care remains in its infancy, there are risks associated with not seeing patients in person and limited physical exams. These risks can be mitigated as part of a well-structured and integrated program.
The need for virtual care
As COVID-19 cases began to rise at the beginning of the pandemic, family physicians and walk-in clinics decreased their service to ensure safety and comply with provincial physical distancing and PPE guidelines. During Wave 1 of the COVID-19 pandemic, emergency departments throughout Canada experienced decreased patient volumes as well, with a skew toward more serious and delayed presentations.2,3
Virtual care was, and continues to be, an innovative, patient-centred, and safe solution to this problem. It serves to increase accessibility and to connect with patients where they are most comfortable. It decreases COVID-19 exposure and PPE usage by supporting physical distancing within the department. By seeing lower acuity cases virtually, in-person clinicians can dedicate more time to those who are more critically unwell and are likely to require hospital admission.
This system is also convenient for those patients who may be wary of attending the ED in-person. They can connect with highly skilled clinicians to determine if an in-person assessment is required for their specific concern at that time. For example, some patients may require routine blood tests but are well enough that they do not require an in-person visit or admission and can safely obtain these tests from a local community lab rather than in the ED.
Complex pieces of the virtual puzzle
Virtual care has many complex pieces both during and after the patient engagement process that must be accounted for. Before implementing a virtual urgent care service, for example, care teams need to ask themselves which populations they are trying to serve and what gaps they are trying to address. As with many interventions, there are risks; implementing digital health solutions could widen the access gap and contribute to digital inequity if concurrent access solutions for lower socioeconomic status patients are not considered.
The scheduling process
The patient intake and scheduling process must also be thoughtfully crafted. This includes balancing the detailed intake form with patient convenience, as both engagement and quality of response influence health outcomes. Additionally, the type of triage system a service uses, such as self-triage or nurse-facilitated triage, will influence the number and type of patients seen and potential diversion to other care options such as a family physician, urgent care, or in person ED.4
Service providers must also consider technology’s role in maintaining continuity of care. Teams should assess how documentation integrates into their virtual care environment and workflows; furthermore, they should assess how these visit records can be seamlessly shared with the pateint’s other providers. In the absence of a truly integrated provincial electronic medical record (EMR), services should aim to have their records easily accessible via the provincial Connecting Ontario platform as well as through Health Report Manager (HRM). This gives providers at different hospitals and patients’ family physicians readily updated information about the patient and their care plan.
Figure 1: The Many Components of Virtual Care (credit: Fadi Bahodi)
Moving forward – where does virtual care go from here?
The overwhelmingly positive response to the virtual care programs across Ontario sends a clear message – many patients love the option for virtual care, and it is here to stay. While these programs are in their infancy, ongoing collaboration and dialogue across services affords many opportunities for system improvements. Patient and provider feedback throughout the design, implementation, and early evaluation efforts have been critical to iterative improvement and will continue to foster an enhanced patient experience while simultaneously ensuring patient safety.
As we head into virtual urgent care 2.0, the opportunities are endless. Regionalization, shared IT systems, and greater coordination of services will help patients access care through a central intake process while reducing inefficiencies within the system. Coordinated marketing efforts, enhanced technological access, and outreach to traditionally underserved and higher risk communities will better ensure that services are available to all. Engaging medical students and residents early in their training and ensuring we are providing opportunities to learn how to deliver high-quality virtual care will help create future medical leaders with enhanced competencies in this field.
You now have a basic understanding of virtual care and how it works. The next few posts in this series will delve deeply into many of the concepts covered here. Stay tuned for our next post where we will discuss virtual care processes in more detail.
- Virtual Care in Canada: Discussion Paper. Canadian Medical Association; 2019:1-24. https://www.cma.ca/sites/default/files/pdf/News/Virtual_Care_discussionpaper_v2EN.pdf
- How COVID-19 Affected Emergency Departments. Canadian Institute for Health Information; 2021:1. https://www.cihi.ca/en/covid-19-resources/impact-of-covid-19-on-canadas-health-care-systems/how-covid-19-affected
- Canadian Emergency Department Visits Drop 25% in Early Weeks of COVID-19 Pandemic. Canadian Institute for Health Information (CIHI); 2020:1.
- Rademacher N, Cole G, Psoter K, et al. Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine. JMIR Med Inform. 2019;7(2):e11233. doi:10.2196/11233
Printed with permission from HiQuiPs. Senior editor for this post was Dr. Shawn Mondoux (@DrShawnMondoux). This post was copyedited by Fadi Bahodi (@fadi_bahodi). Author Dr. Justin Hall is an Emergency Physician at Sunnybrook Health Sciences Centre and faculty member at the University of Toronto. He is a member of Ontario Health’s Virtual Urgent Care Provincial Evaluation Steering Committee. His scholarly interests include virtual care, technological innovation, resource stewardship, leadership training, and quality improvement. Fadi Bahodi is a second-year medical student at McMaster University. His interests are in health innovation quality improvement and digital health.