COVID-19 Raises Profile of Virtual Care

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From a distance: COVID-19 puts more of a spotlight on virtual care’s potential

By Stuart Foxman

Early in the COVID-19 outbreak, patients who tested positive and were self-isolating continued to see doctors from Toronto’s Sunnybrook Health Sciences Centre. The appointments happened often, some even daily, although the patients never left home.

These patients, who had mild-to-moderate symptoms, were followed-up by phone or a secure online platform called COVIDEO. The name was a mashup, with the EO also standing for expansion to outpatients.

Starting in late February, Sunnybrook doctors saw the COVID-19 patients through video conferencing. The appointments covered care strategies and offered peace of mind. Sunnybrook also sent the patients mini oxygen saturation monitors for home use.

The hospital had used the Ontario Telemedicine Network (OTN) before, says Dr. Philip Lam, an infectious disease specialist and Sunnybrook’s virtual care lead. Patients and practitioners had become increasingly comfortable with virtual interactions. With COVID-19, things accelerated. “Boom, there was a massive change,” Dr. Lam says.

Sometimes, transformation happens that way: gradually, then suddenly. In all sectors, people are discovering ways to increasingly operate virtually. Think of everything from online learning for schools, to Zoom meetings for businesses. The technology existed, but now has been adopted more widely. Dr. Lam says that will be true in medicine too: “Virtual care is here to stay.”

A March 2020 study from Canada Health Infoway (which promotes the effective use of digital health solutions), notes that one in six clinicians have provided care virtually. That’s over 27,000 physicians and 40,000 nurses, even before the increase in virtual care as a result of COVID-19.

This wouldn’t be the first time a pandemic triggered major shifts in the health-care system. The Spanish flu of 1918-1920 killed about 55,000 in Canada. The federal government faced criticism for failing to provide resources and coordination to public health authorities across the country. In response, the government created the Department of Health in 1919.

Dr. Kevin Lai

“Virtual is a solution in specific situations. But it does reinforce the traditional adage: it’s the doctor-patient relationship that’s important”

Dr. Kevin Lai

A century later, the rise of virtual care may be one legacy of COVID-19. “When people look back on advances in health care technology, this will be a watershed year,” says Dr. Rashaad Bhyat, family physician in Brampton, and a clinical leader at Canada Health Infoway.

For the doctors delivering virtual care, pre-COVID and beyond, what are some of their lessons and advice?

Shifting gears

Start with the meaning of “virtual”. It doesn’t just mean video.

Dr. Danielle Martin, executive lead for the virtual program at Women’s College Hospital in Toronto, says it can describe any care occurring where the patient and provider aren’t in the same place. They may not even be in those places at the same time. That can include a call, emails, secure texting, a video visit, the use of apps or wearables for remote monitoring, online questionnaires for self-monitoring, and more.

COVID-19 forced many institutions to shift gears. Women’s College Hospital, which already offered many services virtually, ramped up.

For the virus response, the hospital used an online screening tool. People who met certain criteria received a virtual assessment to decide if they needed a nasopharyngeal swab. Other departments like mental health and cardiac rehab used video visits, at a volume 10 times higher than normal. In the Family Practice Health Centre, 80% of patient visits quickly switched to being done virtually.

Women’s College also delivered LTC+, a program connecting the hospital’s medical specialists with long-term care staff (nurses and physicians) for virtual consultations.

In May 2020, after seeing a sharp decline in visits, the Children’s Hospital of Eastern Ontario (CHEO) began offering virtual appointments with an emergency department physician.

“We were worried about kids waiting at home because their parents feared coming to the hospital,” says Dr. Terry Varshney, a pediatrician in CHEO’s ED.

CHEO offered a self-triage checklist online and, if warranted, an appointment using secure video. If needed, patients could come to CHEO for further evaluation, but many issues were handled entirely virtually. Dr. Varshney mentioned one mother who reached out with a mental health concern. She was able to advocate for her young child during a virtual appointment, and was referred to a psychiatrist who also followed up virtually.

Necessity dictated the growth of virtual care during COVID-19. But proponents say the advantages are broad; virtual isn’t the next best thing, but an option in its own right.

“The goal should never be virtual care or face-to-face care; the goal should be the best care,” says Dr. Martin, a family physician.

Impact on experiences and outcomes

At Sunnybrook, Dr. Ilana Halperin, an endocrinologist, was an early adopter of the telemedicine program and OTN. She focuses on diabetes and other hormone disorders, and touts virtual care for “high-frequency, low-touch” interactions, like adjusting medications. Virtual accounts for about 15% of her outpatient appointments.

Dr. Halperin feels she can be connected without being in person. Seeing her patients’ environments on screen can offer insight into their lives and be a conversation starter.

“It’s almost like a home visit, and allows for a human connection,” she says.

Other doctors say virtual care might improve care in some cases. Dr. Ramana Appireddy, a neurologist for the Kingston Health Sciences Centre (KHSC), uses video for follow-ups with stroke patients.

“Being at their location puts patients at ease,” says Dr. Appireddy. “When they come in, they’re not in their comfort zone. At home, it’s a no-stress environment. When you’re relaxed you retain more information. My patients are more compliant, and their health literacy with their condition is better. It’s hard to quantify, but something I’ve noticed.”

A KHSC pilot project around virtual follow-ups for stroke care showed other measurable outcomes: reduced wait times (by 23%), and high patient satisfaction (94% felt virtual visits were the same as or better than in-person visits).

Practicality may be one driver for virtual visits, but other benefits emerge. At the University Health Network in Toronto, the Lung Transplant Clinic conducts 40% of initial consults by video. Some transplant candidates live far away, and all are at high risk. During COVID-19, the team pivoted to an application called Vivify for people transitioning from transplant to home. The app sends doctors back data (e.g. blood pressure, lung function), and allows for one-click video visits.

“When people look back on advances in health care technology, this will be a watershed year”

Dr. Rashaad Bhyat

Patients want convenience and access. Beyond that, Dr. Aman Sidhu, a respirologist on the lung transplant team, says the app monitoring might pre-empt emergency visits and hospital admissions.

“We can also host patient education, to empower people and have them more engaged in their health,” says Dr. Sidhu.

How many visits could happen virtually? At least 50%, suggests Dr. Brett Belchetz, an emergency department doctor at Scarborough Health Network, and co-founder of the virtual care platform Maple.

He finds some patients more forthcoming in a virtual visit around issues like sexual or mental health. The distance might increase comfort levels. While certain exams can only happen live, linked monitors and probes that plug in a phone expand the options.

“We’re just starting to scratch the surface of what’s possible,” says Dr. Belchetz.

Already, he says, he gets a better visualization of tonsils when a patient uses their smartphone camera and light than he might get in person.

What you see on screen can often be enough. During COVID times, Dr. Keith Thompson, a family physician in London, used OTN to do everything from diagnose strep, to check a patient’s post-op wound from ankle surgery. It’s not his first choice, but “In terms of rapport with the patient, it feels no different,” says Dr. Thompson.

Dr. Kevin Lai, a Toronto family physician, has used virtual visits to treat rashes, help a patient having a panic attack, and even (with the patient positioning her phone just right) identify a perianal abscess. He knows there are other dimensions to virtual, but has a higher regard for video.

“I want to see the patient — their affect, how they look, how they’re responding to pain, whether their words match their emotions,” says Dr. Lai.

Dr. Danielle Martin

“We’ll learn where virtual care is most useful, where it’s superior and where it falls short. And we’ll fine tune over time”

Dr. Danielle Martin

What has he learned? “Virtual is a solution in specific situations. But it does reinforce the traditional adage: it’s the doctor-patient relationship that’s important,” he says.

A cultural shift

How might virtual care grow? There are still major issues to resolve: fee schedules, access, training, and the ability of doctors to provide care across jurisdictions.

The Virtual Care Task Force, in a report release in February 2020, also emphasized the need for a strong framework to regulate the safety and quality of virtual care. (The task force was a joint project of the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada.)

The CPSO’s Telemedicine policy outlines expectations for providing care via technologies such as phone, email, audio and video conferencing, remote monitoring and telerobotics.

“Our approach is to be principle-based and not prescriptive. Telemedicine is the practise of medicine. Physicians who practise that way are held to the same standard as those that provide care in-person,” says Dr. Craig Roxborough (PhD), Manager of Policy, CPSO.

One obstacle to overcome: comfort with a new way to work. “Cultural shifts are hard,” says Dr. Bhyat. “We have a lot of the puzzle pieces, but they haven’t been put together to make virtual care a seamless and frictionless experience for patients and clinicians.”

Still, COVID-19 has put virtual care on a faster track. “I think the world has changed forever, and hope the same is true for health care,” says Dr. Halperin.

To some extent, the pandemic experience has been a crash course in virtual care effectiveness and acceptance.

“We’ll learn where virtual care is most useful, where it’s superior and where it falls short. And we’ll fine tune over time,” says Dr. Martin. “Under the right circumstance, the transformation of the system is entirely possible.”

Dr. Martin says the most valid argument for virtual care has nothing to do with whether this model is a suitable substitute for a live interaction. Only one thing matters: what best serves the patient.

That’s not always neatly slotted. With some psychotherapy patients, for example, quality might mean a face-to-face session. Because that’s their preference, or getting out of the house is itself therapeutic. For other patients of the very same service, who find it tough to get out or who feel more comfortable in their home, a virtual visit defines quality.

“The best care will look different in different circumstances,” says Dr. Martin.

To Dr. Bhyat, the operative word in “virtual care” isn’t virtual; it’s care. He says we’ll reach a time when we won’t need the qualifier.

“The term ‘virtual’ will probably vanish,” Dr. Bhyat says. “Virtual modes of delivering care will be seen as just another tool in the toolbox.”

When is Virtual Suitable?

When should doctors consider virtual visits? Health Quality Ontario suggests just some questions to consider:

  • Am I delivering bad news?
  • Am I sharing a diagnosis?
  • How complex is the conversation I need to have?
  • How far is the patient travelling to see me? At what cost?
  • Is it a simple follow-up?
  • Is a physical assessment required?
  • Is this an established patient-provider relationship?
  • Could any language barriers negatively affect the virtual visit?
  • Would a virtual visit be more patient-centered?
  • How tech-savvy is the patient? What’s their cognitive capacity? Do they have someone who can support the virtual visit?
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