The COVID-19 pandemic has transformed how doctors provide health care. This public health crisis has shifted the paradigm on how Canadians access medical care and has ushered in the new era of telemedicine. Almost overnight, patients have stopped walking into their doctors’ offices and are instead receiving medical care through online platforms.
Telemedicine is the delivery of medical care and information through communications technologies. This can be as simple as a telephone call, or can extend into the digital world with email, text messaging and videoconferencing.
But doctors, and the health-care system at large, are often criticized for their limited use of technology to interact with their patients. Emails, text messaging and virtual visits between patients and physicians have been the exception, not the rule. A lack of support for technological infrastructure, poor compensation for telemedicine and concerns for patient privacy have been major barriers to implementing widespread telehealth options.
Telemedicine represented just 0.15 per cent of all billable services in the Canadian health-care system in 2014 (the most recent data). However, with the critical need for physical distancing measures, doctors and provincial health-care systems have been forced to innovate and restructure how they deliver medical care using technological tools.
In simple terms, health care has sprinted into the 21st century.
Dr. Brenda Hardie is a family physician in Vancouver, B.C., and the medical director of a multi-physician primary care office. When it became apparent that the province was starting to see community transmission of COVID-19 in early March, her team worked overtime to adjust to the changing public health recommendations.
Initially, this meant screening each patient for recent travel and cold-like symptoms over the phone before they came into clinic. By the second week of March, it became apparent that physical distancing was the critical piece in mitigating the escalating pandemic.
Hardie says “it was crystal clear” that examining patients and having face-to-face conversations, the very foundation of what is considered excellent medical care, posed a very serious risk to both physicians and patients. Yet Hardie, like the majority of Canadian physicians, had no access to a video conferencing platform that protected patient privacy.
Finding the tools
Hardie’s challenge is one that almost all Canadian physicians have faced over the last month: the limited number of health technology tools have been primarily allocated to rural locations with limited health-care resources. Community, office-based physicians don’t have access to virtual health technology. As such, Canadian physicians have been scrambling over the last month to re-invent how they provide care.
Hardie describes crowd-sourcing information on social media — liaising with colleagues through Facebook and Twitter — to understand what digital platforms others were using. Zoom, Doxy.me and GoToMeeting have all been popular options. E-faxing capabilities have also been critical to ensure prescriptions and requisitions can be sent out.
Yet these platforms are not embedded into electronic medical records (EMRs). As a result, physicians find themselves toggling between their EMR — holding important lab results and consultation notes — and their video screens. The time spent moving between two separate programs adds up and places an extra layer of effort to an already exhausting overhaul. For Hardie, who has switched to seeing 99 per cent of her patients via telemedicine in the span of 10 days, the sudden adoption of telemedicine has been a massive change in her workflow and limits the number of patients she can see daily.
Outmoded payment models
Tied into the lack of infrastructure is the poor payment models for telemedicine across the country. Fee-for-service payment models have been slow to adapt to the new technology. With poor compensation, physicians don’t have the time or financial means to invest in the new technology.
Instead, the innovation is primarily occurring through large corporations and focused on the private, non-insured sector. The way large companies are employing their technology has created concern that health-care apps encourage fragmented and episodic health care instead of the ongoing doctor-patient relationships that are the backbone of a strong health-care system.
With COVID-19 gripping B.C., the province has fortunately responded with changes to payment models. Phone calls can now be billed to the equivalent of an in-person visit — a 70 per cent increase to $34 from $20. Video conferencing fees are also available.
For Dr. Billy Lin, a family physician and clinic owner in Burnaby, the changes are a relief. The fee increases have allowed him to keep his clinic open — for now — during the pandemic. Now, the rest of the country needs to follow suit.
Keeping patients out of emergency departments
The need to keep physician offices open and functioning with telemedicine is critical during this pandemic. Otherwise, patients with flare-ups of chronic diseases, such as heart failure and asthma, will also end up in emergency rooms right next to critically ill patients with COVID-19. This is a recipe for an overwhelmed and collapsing health-care system. Streamlined and effective telemedicine will also allow for the screening of mild respiratory symptoms, be conducive to encouraging self-quarantine and protect health-care workers and the community from unnecessary exposure.
A major challenge with virtual health care is the barrier it creates in examining patients. Prenatal visits and back pain, for example, necessitate a clinical exam. And while doctors are donning personal protective equipment — while it’s still available — to see patients in these instances, telemedicine will remain the mainstay of health care for the months to come.
With no end in sight of the physical distancing measures, rapid and thoughtful investment in telemedicine infrastructure is critical. Perhaps once the pandemic is over, our Canadian health-care system can capitalize on the momentum made in telemedicine. By then, the majority of Canadian physicians will have experience with telemedicine — knowing when it is appropriate to use and when a face-to-face visit is required.
That knowledge, and a new set of virtual health tools, will give the public health system further options to reduce barriers to care and improve health-care accessibility.