We need more virtual care, equity and conversations about what’s truly needed
When we look back on the transformation of health care, the pre-2020 era might be labelled as B.C. — before COVID-19. The battle against the virus is expending much of our time and energy now, but what comes next?
That was the subject of a keynote panel called, “Canada’s Health Care System Beyond the Pandemic,” at the May 2021 Choosing Wisely Canada virtual national meeting. Sharing their reflections and visions were:
- Dr. Danielle Martin, Executive VP and Chief Medical Executive, Women’s College Hospital in Toronto;
- Dr. Ann Collins, President, Canadian Medical Association;
- Dr. Verna Yiu, President and CEO, Alberta Health Services; and
- Moderator: Dr. Wendy Levinson, Chair of Choosing Wisely Canada.
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. As the organization notes, COVID-19 placed enormous pressures on the system to continue to deliver care. That makes stewardship of limited resources even more critical.
That’s always an imperative and is but one fallout from this health crisis. “The pandemic has shifted fundamentally how we work,” said Dr. Levinson.
As we emerge, she said we’ll have all the challenges we had before the pandemic, plus a changed world. How might the health care system evolve? And how do the Choosing Wisely priorities fit in? Here are seven takeaways from the panel.
1. In going virtual, don’t just replicate current encounters
By necessity, the pandemic accelerated the use of virtual care. Technological advancements can support more. It will be an integral part of future health care delivery. But we shouldn’t pat ourselves on the back too quickly with what we’ve achieved with virtual care to date, said Dr. Martin.
Often, that care amounts to no more than telephone visits. Useful, but not revolutionary. Other times, she said, we’re taking a system that was choppy in the face-to-face world and converting that into a virtual version of itself. That’s not where we should stay.
Virtual care can help us rethink the design of health services. But with any form of care, Dr. Martin said we need to be asking three key questions. Is this service necessary? Can it be delivered well without physical contact? What site of service is best for non-physical contact?
2. Avoid low-value care
Virtual care intersects with the Choosing Wisely mandate of avoiding low-value care, said Dr. Martin. If we determine that patients will benefit from our intervention, what is the best way? An in-person visit? Online education? An e-consultation? A call between a primary care provider and a specialty clinic? Something else?
We need to look at the full panoply of ways to serve a patient and what offers the most value in each case. For more about re-assessing care – please read The Pandemic’s Silver Lining.
3. Use an equity lens
The pandemic highlighted serious rips in our health and social fabric. We see it, said Dr. Collins, in how racialized and marginalized populations have been at much greater risk of infections. So have older adults in long-term care through inadequate care and, she commented, ageism.
Good health is about more than simply treating people who are sick. “We’ve witnessed the importance of health prevention and promotion,” said Dr. Collins.
What’s clear, she said, is we must create a more equitable health care system going forward. That includes putting an equity lens on the Choosing Wisely mandate, added Dr. Martin.
Do certain communities receive less care or more low-value care? If so, why? Every health care effort can have equity considerations. For instance, while virtual care might broaden access, Dr. Collins said to consider that not everyone has a reliable internet connection or a computer.
Addressing and acknowledging the social determinants of health is complex, but also essential if we’re to reduce health inequities.
4. Build resiliency
As individuals, our ability to be resilient has affected how we’ve dealt with the pandemic, lockdowns, mental health and uncertainty. We’ve seen how organizational resiliency matters too. “For any health care organization, it’s critical,” said Dr. Yiu.
Organizations have to be able to adapt to disruptions. Doing so depends on having the right people and processes in place. Innovation doesn’t just mean technology, but the way systems can anticipate and respond quickly, Dr. Yiu said. That means maintaining a vigilant posture.
Clinician well-being is part of resiliency. If we don’t have a healthy workforce, we won’t have high-quality care, said Dr. Levinson.
5. Bring patients to the centre
Choosing Wisely Canada reports that up to 30 percent of tests and treatments aren’t needed. These are ones that don’t add value for patients; potentially expose patients to harm; lead to more testing to investigate false positives; contribute to unwarranted stress for patients and their families; and consume precious time and resources.
Health care providers can lead the conversation around what is and isn’t needed. But Dr. Martin said this past year has seen an interesting turning of the tables — many patients themselves have been questioning the need for certain tests and treatments.
Partly, she said, it’s because patients didn’t want to engage with the system for their own safety and protection during a pandemic. And partly it’s because they know the health care system has been overwhelmed.
Either way, “The conversation has been more bilateral than it ever was in the past,” said Dr. Martin. “The question is how can we capitalize on that and not have the onus be only on the provider.”
These conversations should extend to what we need to do and be, broadly, to stay healthy. And why that goal is so out of reach for so many in society, said Dr. Collins.
“This is a real opportunity to bring Canadians to the centre of the health care team,” added Dr. Yiu.
6. Assess deferred care
So many procedures and so much care have been deferred during the pandemic. The huge backlog also provides a unique opportunity. Some procedures may not have been necessary in the first place, said Dr. Levinson, and we can now have that conversation in a different context.
“Choosing Wisely will help us assess what deferred care means,” said Dr. Yiu.
Dr. Yiu said the health care system’s work with Choosing Wisely projects, along with hospitals receiving Choosing Wisely designations, represents a culture shift. It’s one that she says promises to lead to better health outcomes and patient experiences.
Dr. Martin said the conversation around deferred procedures isn’t one that government payers can drive. The public will rightly be skeptical, she said. Trusted health care professionals have to take the lead.
She said it’s also not enough for doctors to say a test or treatment isn’t required. What comes next? What else can be done to address whatever challenges a patient is having?
These conversations aren’t always comfortable, but doctors have to be ready to have them in full. Dr. Collins added one caveat: when we’re looking at alternatives to certain tests and procedures, remember the link to equity. For example, are some alternative services uninsured? We need to think about how all patients can benefit from care solutions.
7. Disrupt the status quo
Clinicians and patients alone can’t solve the problem of overuse. This is a system problem, said Dr. Levinson.
Still, Dr. Yiu said doctors have to remember this is their system and part of their job is to influence it.
Post-pandemic health care won’t be the same, she said. The challenge to medical professionals is to bring open minds and creativity to what it should look like.
The goal is a high-quality, equitable and sustainable system, said Dr. Martin. That means taking a fresh look at how we define health, and where, how and when we provide necessary care.
“We need to disrupt the status quo,” summed up Dr. Collins.
