CMPA Virtual Care Panel Discussion

Panel of experts discuss barriers and enablers to fully integrate virtual care into the health care system

The COVID-19 pandemic gave rise to a rapid adoption of virtual care. However, managing the transition to a hybrid model of both in-person and virtual care requires an understanding that the need to meet the standard of care will determine what model works best for each patient encounter.

The challenges and benefits of virtual care was the subject on a panel discussion held as part of the Canadian Medical Protective Association’s annual meeting and conference.

“In talking to physicians, we are saying `You’re in the position to make the best decision’,” said Dr. Nancy Whitmore, CPSO Registrar/CEO and panel member. “There’s some care that really can be delivered virtually very, very well. There is some care that has to be in person, such as immunizations. And then there’s care that might start with a virtual visit and then needs to transition [to in-person]. I think it’s important to remain flexible as virtual care delivery will continue to evolve,” she said.

During the pandemic, virtual care went from being uncommon and used in limited circumstances to the default model of care, largely by necessity. A study published in the CMAJ found virtual visits accounted for 71.1 percent of all primary care visits in Ontario during the first four months of the pandemic in 2020 compared with 1.2 percent of all primary care visits during the same period in 2019. Between January and April 2021, virtual visits accounted for 38 percent of all the most recent patient reported visits (52 percent of the most recent visits with family physicians).

In deciding whether to provide virtual care to their patients, physicians should be guided by what is in the patient’s best interest. While this may include convenience, more importantly it should be based on the safety of the medical care to be provided, said Dr. Whitmore, referencing the College’s recently approved Virtual Care policy.

In concert with the information session, the CMPA published a white paper, titled “Integrating virtual care in practice: Medico-legal considerations for safe medical care.” In the paper, the CMPA outlines five recommendations to improve safe medical care and reduce medico-legal risk for physician members practising virtual care.

The paper, which aligns with CPSO policy, states that the absence of an appropriate history and physical exam in the exploration of a differential diagnosis is a well-documented, prevailing cause of diagnostic error leading to patient harm.

The report states that access to in-person visits or other services should continue to be readily available when deemed by the physician to be more appropriate, or when patients voice a preference for an in-person assessment.

“There really is no substitution for a good history and a physical exam,” said panel member Dr. Katharine Smart, immediate past president of the Canadian Medical Association.

The term “virtual care” is used to describe any interaction between patients and/or members of their circle of care when they are not physically together in the same room. Whether by telephone, videoconferencing, email or text messaging, virtual care has been embraced by many for the convenience it affords and for its ability to enhance access to care.

The challenge is to ensure these benefits are not outweighed by diminished quality and safety or by heightened medico-legal risks, said Dr. Kendall Ho, an emergency physician and Lead of Digital Emergency Medicine of the University of British Columbia, who moderated the session.

Despite its increased use, the panel members agreed access to virtual care is not yet universal nor equitable, and challenges remain. “The biggest health disparities for anybody are always based in the social determinants of health and access to broadband (high-speed) internet access is a determinant of health,” said Dr. Smart, a Yukon pediatrician. She said very few of the families in her practice have internet access because of its exorbitant expense in the Canadian north. And even for those who do have internet in remote communities, the quality is generally not good enough to support a video-based virtual visit.

But she said virtual care has also afforded a number of benefits for people living in the north, where travel can be difficult. She cites, as an example, the opportunity to bring all the members of the patient’s circle of care into one virtual room for a productive brainstorming session.

“I think for families who have children with medical complexity, one of the real challenges is just having so many cooks in the kitchen. And I think that benefit of hearing everyone collaborating with them around the plan for their child as one unified team is actually really powerful and makes people feel better cared for. It’s much less confusing and you can problem solve together around what to do. So, it just provides much more seamless care,” she said.

Dr. Heather Ross, Head, Division of Cardiology, Peter Munk Cardiac Centre at University Health Network, said she leveraged different technologies to ensure ongoing cardiac care during the pandemic when patients were unable to come into the hospital. Dr. Ross and her team are using smartphone apps, digital platforms and a Bluetooth-enabled monitor implanted in a patient’s lungs to help manage symptoms and triggers of heart failure, educate patients, and limit hospital visits.

In 2018, a report found only one percent of Ontarians who had heart failure were receiving Remote Patient Monitoring despite data that supported the use of RPM in heart failure, she said.

“I do think that COVID made us move at a pace that we probably already should have been moving at,” she said.

Dr. Whitmore agreed. “What we saw, certainly in Ontario, was a phenomenal adoption of virtual care out of necessity. And I think as challenging as the pandemic has been, it’s been an incredible opportunity for innovation,” she said.

But the panel’s messaging was just as cautionary as encouraging. Discussion touched on the problematic nature of virtual walk-in clinics offering only episodic care, and the toll providing virtual care has taken on some physicians who may feel as though it has reduced their effectiveness as clinicians.

Panel member Dr. Pamela Eisener-Parsche, executive director of Member Experience at the CMPA, said questions about safety related to virtual care were among the most frequently asked questions by members calling CMPA during COVID. She said the impact of increasing virtual care on medico-legal cases is still not known, but she acknowledged the existence of member angst about potential risk.

The CMPA report also detailed some of the ongoing challenges with rolling out virtual care in Canada:

• the fragmented approach across the country with respect to interprovincial licensure requirements;
• an inconsistency in standards and guidelines for the reasonable use of virtual care;
• lack of proper infrastructure and training about the various modalities of virtual care; and
• lack of access to secure virtual care platforms.

In its examination of the future of virtual care, the CMPA recommends existing processes for managing follow-up care, making investigation requests, and documentation processes designed for in-person care being modified to also accommodate virtual clinical encounters. The CMPA advises, however, that virtual care should only be offered when appropriate to the circumstances and when it will meet the patient’s needs.

The CMPA also recommends education on the provision of safe virtual care be incorporated into medical school curriculums in undergraduate, graduate and continuing professional development programs.

Dr. Ewan Affleck, a Yellowknife physician, says a pan-Canadian framework is needed to establish excellence in virtual care that upholds quality health service and supports continuity of care among care teams. Without such a framework, the risk exists that a series of fragmented virtual care services will be established that detract from continuity and potentially lead to quality of care issues, he said.

Domenic Crolla, General Counsel to the CMPA, says to ensure “medical values” are incorporated into virtual care and other new technologies, physicians must be “very vigilant” in involving themselves in conversations about their use.