Can virtual health care help save a collapsing system?

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Jordan: You’ve almost definitely had your healthcare delivered to you virtually, even if you didn’t see it that way at the time. During the pandemic, of course, many Canadians became familiar with virtual doctor’s appointments via either phone or video calls for questions about their health or referrals to other providers. That was a little bit new, but even before Covid, did a doctor ever call you up to deliver a test result? Ever email you a prescription or a referral for a blood test or an X-ray? Congrats you’ve had virtual healthcare. The question though, as we move out of the pandemic, is if further reliance on virtual care could be a help or a hindrance to our already overtaxed system. For instance, does an initial phone call appointment streamline the care process or does it create one more unnecessary appointment before an in-person visit? Does virtual care improve access or encourage overuse or both? Technology right now has the potential to move Canada’s healthcare system into the digital age at long last, but only if we can find the right balance of efficiency and in-depth care. So how do we do that? I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Tara Kiran is the Fidani Chair in Improvement and Innovation at the University of Toronto, as well as a family physician and scientist at St. Michael’s Hospital Unity Health Toronto. Hey Tara.

Dr. Tara Kiran: Hello.

Jordan: Thanks for finding some time for us.

Dr. Tara Kiran: Yeah, my pleasure to be on the show.

Jordan: I wonder if maybe you can start with a simple definition. I don’t actually know if this definition is simple, but when we use the term virtual care in Canada talking about medicine, what does that cover?

Dr. Tara Kiran: Yeah, great question. I mean, because I think people can think about different things. So the way I think about it is it generally refers to an encounter with the healthcare system, usually an encounter with a healthcare professional that leverages technology and that technology can be old school, so it could be a phone or it could be newer technology like a video or email or secure messaging or SMS or text conversation. And importantly, that care can be synchronous, so that means the clinician and the patient may talking to each other virtually at the same time, or it can be asynchronous. So one person is sending a communication and then the other is communicating back at a different time.

Jordan: Maybe you can give us a sense for the purpose of this conversation of what are some of the more obvious kinds of services that could perhaps be best served by virtual care and taken out of the need for face-to-face interactions?

Dr. Tara Kiran: So I think about the types of services that are more straightforward in nature, and especially actually in more than the services I think of context. So if we think about services, we can think about something like I’m a family doctor. The kinds of ways when I might use email or a phone call might be, for example, to follow up on test results, especially if they’re normal test results and I just need to send a quick communication around that. Or if I want to follow up and send some further information to a conversation I had, that’s a great way for me to use email. If someone’s not able to come into the clinic because let’s say they’re having a hard time getting childcare, or they’re really not feeling up to coming into the clinic for different reasons, they can’t get transportation. Virtual care is a really important way in which we can still connect with the patient and we might use more than one way to connect. So we might talk to them on the phone and then ask ’em to send a photo, for example, where we can take a look at something. So for me, more than the actual type of encounter, it actually relates more to the context because we know virtual care is also best used in the context of an ongoing relationship where you already know the person. And so even when you see someone virtually, you’re not necessarily getting the whole picture, but if you know them as a person and know their situation, you don’t necessarily need all the information you would get in person in the same way that you would if you didn’t know the person.

Jordan: How long has virtual care been around and can you kind of chart maybe the rise of it for us? Is this just a creation of the pandemic or was this being used previous?

Dr. Tara Kiran: So if we think of virtual care encompassing phone calls, then it’s been around for decades for ages.

Jordan: Right.

Dr. Tara Kiran: And it’s true that the pandemic did change things, but one of the ways it changed things was that it actually started to pay doctors more explicitly for providing care virtually. And then as a result of that, we also started to count actually when people were having an encounter that was based on the phone, whereas before, for example, when it was a phone call, we didn’t even think of that necessarily as an appointment. And in fact, few doctors would actually book an appointment that was deliberately a phone. So what we saw in the pandemic was a huge rise in virtual care for a variety of really good reasons, including just trying to protect people from having to come in and unnecessarily expose them to potential infection. Partly that was facilitated through doctors being finally paid for that kind of work, and doctors then rejigging their appointment schedules so that patients actually would be able to book not just an in-person visit, but a phone call. So phone calls were actually the predominant way in which people got care early on in the pandemic. And so when we talk about the rise of virtual care and the pandemic, what’s really interesting is that actually it’s not the new fangled technologies or newer technologies like video and email that really skyrocketed as much as the use of phone calls.

Jordan: How standardized and available is a virtual care to patients across Canada? Is there any standard that doctors are required to follow or is it very wildly like clinic to clinic?

Dr. Tara Kiran: You know what, there’s huge variation. We did a study just following the first year of the pandemic to take a look at virtual care practices. And what we saw was that there were huge variations across clinics in terms of how much care was being provided virtually as well as even within a clinic. So let’s say you had 10 doctors or 20 doctors practicing in the same group. Within those 10 or 20 doctors practicing in largely the same context, they would have really potentially wide variation in how much virtual care they were using. So it really is doctor and clinic and patient dependent because one big factor relates to your patient population and how important virtual care is for them and how accessible it is for them. Other research we’ve done has actually asked patients about whether they’ve encountered virtual care. So we did a very large national survey is part of an initiative called OurCare, where we’re aiming to engage the public about the future of primary care in Canada. And the survey was done in the fall of 2022, and we asked as part of that survey, and in the last 12 months for people who had a family doctor or nurse practitioner, what kind of encounter did you have? And about 70% said they had a phone encounter, about 18% said they had about an email or secure messaging type of interaction, and only about 5% said that they used video. So it really shows how phone calls have become really a predominant motive providing care, but we have a ways to go in terms of integrating other modalities.

Jordan: Because you mentioned this survey, I have to ask for some more details. Do we know what Canadians think of virtual care, how they compare it to in-person care, what they prefer, that kind of stuff?

Dr. Tara Kiran: Yeah, a really great question. So in addition to the survey, we actually also had conversations with over 350 people across Canada over the last 16 months. These were deep dives where people spent 30 to 40 hours with us learning about primary care and providing recommendations for a better system. And as part of that, we learned a few things. So for when people predominantly still want to ensure that they can have in-person access to their family doctor or nurse practitioner or clinician, that’s definitely the most important mode for them. But people also want to have to virtual care. So for them it’s an add-on and they want it as an option and they want it to be integrated with the in-person care. So having a standalone virtual care clinic isn’t meeting their needs or what it is that they want. And interestingly, people also recognized that it was really important if we’re going to deploy virtual care across Canada, that it should be done in a way that actually really supported equity and access because they recognize that there’s some context in which virtual care is so critical and important, and in particular, that’s rural and remote areas where we know we often don’t have the clinicians that we need and people might have to travel really long distances, disrupt their lives in order to get the care that they need, whereas virtual care offers a way for them to be able to access care without that inconvenience.

Jordan: One of the reasons that we’re talking to you today about virtual care and that you guys are talking so much about virtual care is because we all understand the strain, to put it mildly I guess, on the healthcare system in this country right now, how does virtual care or how could virtual care impact that? I mean positive or negatively, and what are the ramifications?

Dr. Tara Kiran: I think the truth is we’re not really sure how it’s going to go with virtual care. There’s a scenario where virtual care might be able to make us more efficient and increase access to care, especially for example, in rural and remote areas. But there’s also a scenario where actually where virtual care can make things more inefficient and actually increase costs. So as an example, in some of the ways it was implemented during the pandemic, one thing we saw was that sometimes there was a double visit. So patients might talk to the clinician virtually on the phone or maybe through an email and they might get a bit of a response around something, but then they might be told to come in because they needed to really be seen in person in order for them to be properly assessed. And so what you have there that happened is a double visit, both a virtual and then an in-person visit. The other thing that happens with virtual care is that people worry that it’s actually lowered the threshold of when it is that people want to engage with their healthcare clinician. In some ways, some types of virtual care make it such easy access that they have something smaller that’s wrong or something that they haven’t given it a day or two to see If it gets better and they just want an immediate answer, they’re going to contact a clinician. Whereas if they were booking an appointment and they had to come in, they might give it a bit more time because they didn’t want the hassle of having to go in and just wanted to see if it gets better. And actually there are a lot of things in healthcare where things do get better over time, but what virtual care might do is actually lower the threshold for when people ask for care. So that might increase the demand. And then what we might have, well, increasing the demand is that kind of double visit. So you can imagine then that virtual care actually could be constructed in a way that it’s less efficient and more costly. We can also imagine scenarios where virtual care is provided outside of family doctor care. So for example, we’ve done some research that shows that if you get virtual care in a standalone virtual care clinic as opposed to with your family doctor, you’re much more likely to go to the emergency department. And that drives up healthcare costs and demand. So we need to really be careful with how we implement virtual care, that it’s in a way that actually reduces inefficiencies and improves access and equity as opposed to growing our costs.

Jordan: Do we have a plan, like an actual cohesive plan for how we implement virtual care? I mean, you just kind of said a few minutes ago that this is varying doctor by doctor and clinic by clinic. What’s the big picture on this?

Dr. Tara Kiran: Yeah, it’s a really good question. I mean, to be honest, I think in some ways we kind of have to take a step back and look at the whole space of digital technology, which goes beyond just virtual care, but also in terms of how people access information, how people interact with the healthcare system. And when I look to other countries, and when I think about how our patients responded to what they said was important to them, one of the things that comes out as being so critical is actually just access to their own information online. So digital technology should allow us to be able to provide patients with access to their own health information. Patients say that’s one of the most critical things, and we can see that many high-performing healthcare systems in other countries, for example, Norway, Finland, Denmark, you can look up your information online. And so when I think about a strategy for implementing virtual care and digital technologies, I kind of see us needing to start with some of those basics, access to people’s own information and empowering people to better navigate the system and care for themselves.

Jordan: How might it be possible to actually implement a system like that across this country with all the jurisdictional challenges that creates from province to province over what the standards for this are, what the levels of access for this are? And if we’re implementing an entire new tier, I guess for lack of a better word into our healthcare system, should there be some kind of oversight to ensure that patients in Quebec aren’t using virtual care completely differently from patients in British Columbia?

Dr. Tara Kiran: I think there absolutely does need to be oversight. Patients and members of the public told us that they wanted virtual care that was publicly owned and accountable, and I think we have to really think about how we make that happen, that this isn’t done in disjointed ways where sometimes if it’s done without public ownership and accountability, it’s possible that financial interests of different care providers may actually drive what it is that is being offered when it really should be the interests of patients and the public. So I think that’s fundamental. I think the second piece I’ll put forward is when I think about one of the most critical problems that people in our care cited that they wanted to have fixed, it was access to their own personal health information. And there were actually many recommendations that they put forward related to that. And one related to legislating or mandating inter-operability between different electronic medical record systems. So right now we have siloed systems. So you may see one family doctor and that family doctor may not have access to your hospital record or vice versa. Same thing with the specialist, or let’s say you have community care and then of course you may change family doctors or move to a different province and those records don’t follow you and they don’t interact with each other. So we need to make it compel the vendors who make electronic medical records and who put those on the market to ensure that they are doing it in a way that the different systems talk to each other and that they’re also building in processes for patients to be able to interact with the data.

Jordan: I’m always amazed when I talk to physicians in Canada and about access to medical records and the ease of transferring information that it’s the only time in my life I ever bring up the fax machine anymore.

Dr. Tara Kiran: Yeah, it’s true. We’re still living in the 1980s. We use faxes all the time. To be honest, I don’t think it’s the biggest problem in our healthcare system, but it’s certainly a symbol that we haven’t moved forward to modernize what is so near and dear and important to everybody living in this country

Jordan: Returning to virtual care as opposed to records, what are the barriers to making it equitable? And here, I think there’s one thing that everybody kind of agrees on in the healthcare system right now is that the aging boomer population is one that’s going to require a lot of resources, I would imagine. Obviously not all of them, but I would imagine that those are the less tech savvy people in Canada, and how do we make sure that they’re able to access the services that we want to make available this way?

Dr. Tara Kiran: Yeah, so we did an interesting survey of hundreds of doctors in the Toronto area. This was a couple of years after the pandemic started, and we asked them what kinds of supports would be needed if virtual care was going to be continuing to be a big part of the care that they delivered. And the first thing they said is that they needed some infrastructure support. But actually the second thing that they said, which was really interesting, was that they wanted to have supports for patients to be able access the virtual care. Because what’s really tricky as a doctor is we have limited time in terms of our appointments. And it’s unfortunate if let’s say you’ve booked a video appointment or a phone appointment or you want to do something by email and you want to be able to use the time you have with the patient to really focus in on that clinical encounter and what their problem is, but then you end up spending time trying to help them sort out how they can actually use the technology, and that’s not a good use of our time. It’s not often a good use of our staff’s time. We don’t have more staff to be able to do that than we would if we were just being seen in person. So a really important part I think is supporting people to have access to the technology and supports to use that technology. The patients in public who participate in our care made some really specific recommendations too, so if we want to enhance access to care in rural and remote areas, they said, well, we need better internet. We also need hubs or places where people can come if they don’t have access to the internet. So public spaces like libraries or others should maybe be modified so that people can actually do a virtual appointment from there. And maybe then people are also supported to be able to log on and actually have that appointment in a safe space that doesn’t require them to figure it all out on their own.

Jordan: It seems to me through this conversation that there’s something of an inflection point here. We’ve gotten more used to and accepting of virtual care throughout the pandemic, and as you pointed out, it’s got the potential to become more efficient or make our healthcare system less efficient from where we are right now. When you look ahead five years or so, say, what role do you think virtual care plays in the healthcare system in Canada and what do we need to do now to make sure we get that right?

Dr. Tara Kiran: I’d love to see virtual care play a role in augmenting access to care. It’s like a tool in our toolbox. It’s not the only tool. We need to figure out how to best use that specific tool in a way that actually makes access better for people, especially people who struggle the most with access. And so I think to do that, we need to be guided by patients in the public. That’s why we spent so long trying to speak with people and actually unearth the values that they wanted to see in the system. And they were pretty clear. They want virtual care integrated with in-person care. They want virtual care that’s publicly owned and accountable. And they want virtual care that enhances equity and access. And so if I think if we stay true to that North Star that patients in the public point us towards, I think we’ll be in good stead. And I also want to make a plug to say that I think we actually have to evaluate how we’re doing, so we need better data to understand how it’s being implemented and then what the effects are, both in terms of access and efficiency, also equity and also costs because I think some of the choices we’re making right now, we’re not always in the best interest of the whole system and in particular, those who are most understood.

Jordan: Tara, thank you so much for this. It’s a fascinating subject and well, I guess we’ll see where it goes.

Dr. Tara Kiran: Thanks so much,

Jordan: Dr. Tara Kiran of the University of Toronto and St. Michael’s Hospital. That was The Big Story for more including lots of episodes on our broken healthcare system, including some that offer solutions. You can head to The Big Story podcast.ca. While you’re there, don’t forget to check out the first episode of Paydirt, which dropped this Monday. If you missed it, you want to listen to that before next Monday because in episode two things get even wilder. You can offer us your feedback on Paydirt or this episode or any episode by emailing us. hello @ The Big Story podcast.ca. Is that address or by calling us 416-935-5935. The Big Story is in every single podcast player, and it’s on every single smart speaker. You should know that by now, in case you don’t. The way to get it on those smart speakers is by asking them to play The Big Story podcast. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.