“Virtual care” is defined as any “interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies with the aim of facilitating or maximizing the quality and effectiveness of patient care” [1,2]. It includes services carried out using a variety of digital technologies, both synchronously (occurring in real time, such as telephone and video communication) and asynchronously (occurring at different times, such as secure messaging) [3].
When an in-person visit with a healthcare provider isn’t possible or even desirable, having access to virtual care can mean the difference between a patient receiving the care necessary to improve their health or dealing with the consequences of untreated ailments. When patients and clinicians opt for virtual care, they can help prevent the spread of infections, save time and money, engage in more timely medical interventions and enjoy flexibility with regards to receiving and delivering healthcare [4].
Virtual care can benefit a variety of patients, such as people with mobility issues, residents living in remote areas and busy parents and workers who want the convenience of connecting through their device (possibly avoiding child-care services or time off work, as a result). Considering the benefits, it’s no surprise that the adoption of virtual care solutions and services is growing across Canada’s entire health system, and it is being recognized how virtual care can address the diverse needs of patients and healthcare providers to deliver safe, timely and equitable care [4].
As the pandemic emerged in Canada, governments introduced measures to limit the spread of COVID-19, including lockdowns and recommendations for physical distancing. These measures led to an initial reduction in interactions between physicians and their patients. In subsequent months, however, visits resumed, with many shifting to virtual appointments by telephone, videoconference and online messaging. Since that time, virtual care has remained significant in Canada [5]. In March 2022, about half of Canadians reported that they had been offered a virtual visit alongside other non-virtual modality. Between January 2021 and March 2022, about one-third of all patient-reported visits were virtual, and 38% of family doctor visits, 27% of specialist visits and 16% of visits with other healthcare providers (e.g., dentists, physiotherapists) continued to be conducted virtually [6].
Virtual Care includes several concepts/domains (types of virtual care), some of which are presented here [7]:
Telehealth: Delivery of healthcare and related clinical/non-clinical services such as patient to provider interaction, provider to provider interaction, healthcare education, self-care, and health information services remotely using telecommunication technologies such as computers, mobile devices, and wearable devices.
Telemedicine: A practice of medicine for the purpose of diagnosis and administering patient care involving usage of Information and Communication Technologies (ICT) by a healthcare provider. Historically, this was predominately for patients/families who are located remotely, however, this is no longer the case.
eHealth: The application of ICT by a healthcare provider in the form of electronic health records, hospital information systems, remote monitoring systems, and electronic messaging systems to administer healthcare to patients.
Telemonitoring: Monitoring and electronic transmission of patient health status between geographically separated individuals using ICT by web based, phone based or automated electronic data entry.
Teleradiology: Usage of ICT to electronically transfer radiological images such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, nuclear medicine studies from one location to another or provide access to such data from a remote location without making a copy for interpretation and/or consultation.
Telepsychiatry: Branch of telemedicine involving delivery of psychiatric services including evaluations, therapy, patient education and care using ICT.
Telepathology: Usage of ICT to electronically transfer pathology data between remote locations or provide access to such data from a remote location without making a copy in the form of an image or video for purpose of diagnosis, research, education and external quality assessment.
Telepharmacy: Use of telecommunication technology by pharmacists to oversee aspects of pharmacy operations or provide patient-care service.
Consumer Health: A consumer health application is an electronic solution that enables the consumer to collect, retrieve, manage, use and share personal information and other health-related data. A consumer health application could include solutions commonly described as personal health records (PHR), patient portals, telehealth and telehomecare (remote patient monitoring), and could be used in mental health, chronic disease management, long-term care, etc. Consumer health products are products sold directly to consumers. Health Canada has determined that with enough supporting information and instructions, consumers can safely select and use these products to maintain and improve their health.
The following virtual care capabilities, defined as functions, may be utilized or implemented within various virtual care concepts and domains [7]:
- Phone
- Messaging
- Video visit
- eConsult/eReferral
- Patient portal/PHR
- Remote monitoring
- Patient education
- Online assessments
- Case conferencing
Virtual care capabilities may be delivered or executed either synchronously or asynchronously or both [7]:
Synchronous: Involves the use of technology to enable individuals or care teams to interact with their care in live/real time (or synchronously) format. Examples include phone, video visits, online education programs.
Asynchronous: Involves the use of technology to enable individuals or care teams to interact with their care through methods that do not require real time interaction e.g., messaging, patient education, review of patient documentation, toolkits, personal health records that patients have access to.
Initiatives by Government of Canada
The COVID-19 pandemic resulted in provincial and territorial governments rapidly accelerating the deployment of virtual care across Canada so that Canadians were able to effectively access publicly funded healthcare services in a safe, physically distanced manner. However, the rapid deployment of virtual care impaired the capacity to constructively apply the appropriate design features required to promote quality of care, and specifically equitable health services. It is recognized that virtual care, if not designed thoughtfully, has the potential to exacerbate the digital divide, and compromise health equity [8].
To promote collaboration, the Federal, Provincial, Territorial (FPT) Virtual Care/Digital Table was struck in March 2020 with a mandate to consider and develop a proposed plan for accelerating the deployment of virtual care in Canada both during COVID and for the longer-term [8].
The Canadian federal, provincial and territorial governments have been working collectively to accelerate efforts on virtual care through a focus on three main areas of work [9]:
- Funding to provinces and territories through bilateral agreements and support by Canada Health Infoway, with shared priorities for technology and infrastructure. These priorities include secure messaging and information-sharing; secure videoconferencing; remote patient monitoring (RPM); patient access to test results; and back-end supports to enable integration of these new tools into existing digital systems.
- Evaluation of impact of virtual care to improve patient care and outcomes, as well as the efficiency and sustainability of care.
- Policy supports for virtual care to develop a federal, provincial and territorial policy framework, which identifies barriers and opportunities for longer-term adoption of virtual services within Canadian health systems.
This work on virtual care is laying the ground for a more permanent shift to virtual services as an additional channel for access that complements traditional face-to-face models of care [9].
Virtual care should advance the principles of the quadruple aim by: improving patient experience, quality of care and health outcomes; strengthening population health outcomes; delivering better value in the delivery of care; and, improving provider experience in the delivery of care. Based on these broad principles, the goals and desired outcomes of virtual care work is to [9]:
- Enhance access to care – Better integration of virtual care services and tools within the health system could enhance patient access to care at home and in the community as part of publicly funded health services. It could also serve as a tool to improve equitable access for Indigenous, vulnerable and remote/rural populations, so long as barriers related to digital literacy and affordable, reliable access to broadband are addressed.
- Provide high-quality, appropriate and safe care – Virtual care provides an opportunity to deliver high-quality, patient-centered and appropriate care. Virtual service delivery could significantly improve the continuity and coordination of care.
- Protect and strengthen the publicly funded healthcare system – Patients should continue to have access to physician and physician-equivalent services without having to face patient charges, regardless of whether these services are received virtually or in-person.
- Improve patient and provider experience of care – Virtual care offers a complementary avenue for the delivery of care, through multiple modalities, which has the potential to provide more accessible and convenient care for patients and offers the potential for better collaboration between providers supported by virtual/digital tools.
- Improve health system efficiency –The policy enablers should consider virtual care through a value lens so that it is introduced and deployed in a manner that supports appropriate returns on investment and health system sustainability.
Health Canada has released a Virtual Care Policy Framework to allow for sustainable use of virtual care technologies in Canada in keeping with shared goals and outcomes. In order to deliver on the goals and outcomes, the following policy pillars have been identified [9]:
- Patient and community centered approaches
- Equity in access to virtual care services
- Renumeration/compensation models to ensure patient-centered and high-quality care, and support sustainability of the healthcare system over the longer-term
- Change management (e.g., training, integration of virtual care tools with existing clinical practice and workflows)
- Appropriateness, safety and quality of services to ensure that virtual care is appropriate and safe for the condition being treated and that patients receive high-quality care
- Licensure (a critical enabler of facilitating the delivery of virtual care across jurisdictional boundaries)
As part of this work, equity emerged as a critical issue, and there was interest from FPT governments to examine how best to ensure equitable access to virtual care within the publicly funded healthcare system. The Task Team on Equitable Access to Virtual Care (Equity Task Team) was created under the Virtual Care Expert Working Group with a mandate to develop a principle-based framework for equitable access to virtual care and provide guidance and recommendations on the concrete actions that FPT governments can take to ensure that virtual care promotes equity as a critical dimension of quality care [8].
Conclusion
Since the arrival of the pandemic, health systems have worked quickly to deliver virtual care services in an equitable way, using appropriate modalities for patients and providers. In doing so, they faced common challenges related to standardized data collection and resource constraints, and benefited from patient and provider engagement throughout the process of planning and implementing their work. Provinces and territories are now focused on how to build sustainable, integrated virtual care options, and on maximizing available resources to deliver more seamless patient-centered care [3].
Building a foundation of data standards is crucial to support health system performance measurement and to achieve interoperability between and within health systems. As provinces and territories consider how virtual care can become an integrated part of their health services beyond the pandemic, there is a requirement for standardizing virtual care data, measuring the delivery and impact of virtual care services, and continuing to learn from each other [3].
Technology has enabled care to move beyond the four walls of a clinician’s office. Virtual care can be a safe and convenient way to access care. Canada Health Infoway has several resources to help Canadians learn more about virtual care, including some tips to prepare for their next doctor’s visit [10]:
- What is Virtual Care?
- Understanding Virtual Care — The Benefits and Considerations
- The Benefits of Receiving Health Care Virtually
- Virtual Health Services in Your Province or Territory
- Virtual Appointment Checklist
- How to Prepare for a Virtual Appointment
- Provincial and Territorial Digital Health Priorities
Author: Pratibha Duggal, ICON Plc.
References:
- Canadian Institute for Health Information. Virtual Care in Canada. Accessed 28 February 2024. At: https://www.cihi.ca/en/virtual-care-in-canada
- Canadian Medical Association (CMA) Health Summit. Virtual Care in Canada. Discussion Paper. Accessed 27 March 2024. At: https://www.cma.ca/sites/default/files/pdf/News/Virtual_Care_discussionpaper_v2EN.pdf
- Canadian Institute for Health Information. The Expansion of Virtual Care in Canada. New Data and Information. Accessed 28 March 2024. At: https://www.cihi.ca/sites/default/files/document/expansion-of-virtual-care-in-canada-report-en.pdf
- Canada Health Infoway. VIRTUAL CARE. Creating a more accessible and sustainable health system. Accessed 01 April 2024. At: https://www.infoway-inforoute.ca/en/digital-health-initiatives/virtual-care
- Canadian Institute for Health Information. Virtual care: A major shift for Canadians receiving physician services. Accessed 01 April 2024. At: https://www.cihi.ca/en/virtual-care-a-major-shift-for-canadians-receiving-physician-services
- Canada Health Infoway. Canadians’ Health Care Experiences During COVID-19. Uptake of Virtual Care. 2022. Accessed 01 April 2024. At: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3828-canadians-health-care-experiences-during-covid-19?Itemid=103
- Digital Health Canada. Virtual Care in Canada. CHIEF Executive Forum Virtual Care Working Group. Accessed 25 April 2024. At: https://digitalhealthcanada.com/wp-content/uploads/2022/06/Virtual-Care-National-Lexicon-v-JAN2521.pdf
- Government of Canada. Enhancing equitable access to virtual care in Canada: Principle-based recommendations for equity. June 2021. Accessed 02 May 2024. At: https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/bilateral-agreement-pan-canadian-virtual-care-priorities-covid-19/enhancing-access-principle-based-recommendations-equity.html
- Government of Canada. Virtual care policy framework. July 2021. Accessed 27 May 2024. At: https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/bilateral-agreement-pan-canadian-virtual-care-priorities-covid-19/policy-framework.html
- Canada Health Infoway. Learn about Virtual Care. Accessed 27 May 2024. At: https://www.infoway-inforoute.ca/en/patients-families-caregivers/digital-health-learning-program/learn-about-virtual-care