Throughout 2020, and especially since March when the pandemic hit, there has been a flurry of innovationto solve problems in every area of life, especially in health care.
“Early COVID-19 days, people that weren’t even in health care, like engineering firms and math firms, were all just bringing ideas together and working with the public sector to try and make things like PPE and virtual tool kits. It was coming from a bunch of different angles,” says Cory Fry, director of consulting services for CGI, a Canadian multinational management consulting and IT services firm with about 75,000 team members worldwide, including about 300 in B.C.
“Our key focus these days has been the digital transformation of the public sector, helping them to embrace some of those new technologies,” says Fry. “We support them in a lot of different ways, whether it’s IT systems, strategy, analytics — we’re an end-to-end services firm.”
Public health care is a complex system of multiple organizations and regions influenced by financial and political factors, all of which can limit the rate of innovation. Fry refers to the ongoing debate between public and private health care, especially with respect to technology.
“One of the big questions that always remained is: Can the private side innovate faster than us?” says Fry. “Private sector, if the money’s there and there’s a buyer, they could just move forward.”
Until the pandemic.
“[COVID-19] really accelerated the innovation that was already happening within the public sector,” he says.
By way of example, Fry refers to a project involving CGI, the B.C. Ministry of Health and five provincial government agencies working on the COVID Digital Assistant, a digital chatbot that helps triage questions that overwhelm call lines. Within two weeks, the chatbot was live, fielding thousands of questions from the public: do I need to be tested and where should I go? Should I send my kids to school? Should I go to work?
“Six months previous, there was no such thing as a digital chatbot service,” says Fry. “And within two weeks, they had something up.”
That’s just one of many advances adopted since March 2020. Virtual health care is another, one that is transforming how we access health care services in the province.
Changing How We See The Doctor
As Fry points out, COVID-19 accelerated innovation that was already happening within the public sector. Virtual care is the perfect example of that. It’s not that virtual care is new — it isn’t really — but until the pandemic, the use of it in B.C. was less common, despite research pointing to its benefits.
“In 2019, even before the accelerated deployment of virtual health services, the data showed that virtual care saved approximately 11.5 million hours for Canadians who didn’t have to take time off work to attend in-person appointments,” says Sue Paish, CEO of the Digital Technology Supercluster, a cross-industry collaboration of diverse organizations. “So that in and of itself contributes to maintain productivity.
It also saved, because of reduced travel time, more than $595 million in travel costs for going to and from physician in-person appointments or quick clinic appointments. And this, in turn, resulted in 120,000 metric tons of CO2 emissions being saved.”
While there hasn’t yet been an equivalent analysis done since the start of the pandemic, we do have some projections from Canada Health Infoway, a federally funded not-for-profit that provides data and analysis on health technologies.
“[Canada Health Infoway’s] projection is that if we continue to have virtual visits for roughly 50 per cent of visits, we can save approximately 103 million hours for Canadians every year, $770 million in travel costs, and 325,000 metric tons of carbon dioxide, so CO2 emissions,” says Paish. “That’s the best forecast we have. These are significant numbers.”
Keep in mind, too, that virtual care is more common in other parts of the world.
Dr. William Cunningham, head of Island Health’s primary care department and the medical director for Urban Greater Victoria (Portfolio 4), says in many countries 60 to 70 per cent of care is delivered through virtual care. And that’s without a pandemic.
“COVID-19 has really pushed primary care to deliver services in a different way and, really in a better way, not only here in Victoria but also elsewhere in B.C.,” says Cunningham. “Face-to-face meetings are very important in primary care, in particular, where a physical exam is required. Many interactions can, however, be done well and to a high quality through the virtual care options.”
Some virtual care was already in place before COVID-19. Cunningham points to Home Health Monitoring, a free service to support people living with chronic obstructive pulmonary disease, chronic kidney disease, diabetes, heart failure and hypertension to help patients manage their conditions at home with the daily support of medical staff. Cunningham also names my ehealth, a secure website that provides patients with 24-7 access to personal health information, including laboratory results, medical imaging reports, clinical documentation and outpatient appointments. Both programs encourage people to play a more active role in their own health care.
But for actual appointments with physicians and specialists, virtual care was minimal before the pandemic.
So what stopped us?
“An important and necessary enabler was that the Ministry of Health created fee codes that could be used and then also encouraged virtual care to be used,” says Cunningham. “Without those, it would not work.”
Previously, doctors didn’t have a way to charge appropriately.
“Due to changes made early on in the pandemic, the fees paid to physicians for virtual care and in-person care are the same, which removed financial incentives from decisions around the type of visit that is appropriate for the patients,” says Dr. Aaron Childs, a Victoria- area family physician. “For the first time, the medical care is valued the same, no matter where it is delivered.”
This fee structure change also allows more flexibility for patients and doctors.
“In B.C. we’ve been well supported by the ministry in the switch to virtual care,” says Dr. Jaron Easterbrook, a Victoria-area family physician. “This certainly makes it more convenient for patients who no longer have to drive to the office, find parking and then wait in my waiting room — all for a simple conversation that might take 10 minutes”
So far, it is working fairly well.
How it’s going in Family Medicine
Interestingly, Childs and Easterbrook didn’t know each other before the pandemic but since then have worked hundreds of hours together as co-chairs of the Greater Victoria COVID Community Task Group, a collaborative partnership between the Victoria and South Island divisions of Family Practice and Island Health and a force behind the shift to virtual appointments.
“To be honest, I only started offering virtual visits in January [2020] as a way to offer an extra hour of visits in the morning but still be able to walk the dog once the sun was up,” says Easterbrook. “Then COVID-19 hit shortly after, and, for the first couple of months, everything was virtual.”
Easterbrook says the rapid change from in- person to video or telephone visits brought about a huge culture change in how family medicine is conducted. While the balance between in-person and virtual visits levelled off to about half and half in the following months, alternating the types of visits minimizes the number of people in his waiting room and allows for additional cleaning between patients.
Both doctors say virtual visits work well for follow-ups, discussions about prescriptions and reviewing lab results, while in-person visits are better for new or evolving symptoms that require physical assessment.
“Last year, I would see on average 125 patients in person per week with the occasional telephone follow up,” says Childs. “Now, I see 115 patients virtually per week and 12 to 15 people in person who need a physical exam. It has been a complete transformation of how I provide medical care.”
Childs adds that approximately 85 per cent of virtual visits with his patients are conducted by phone, primarily due to patient preference, with the option chosen online at the time of booking.
“Video visits will likely become more popular over time, but there are sometimes challenges with the connection and audio, like most video conferencing,” says Childs. “I usually can connect with patients by telephone if things don’t work with video, but it does affect the amount of time we have left for the medical visit.”
Easterbrook also falls back to the phone if there are challenges with technology. In general, his patients love virtual care.
“Especially when I’m running late — my assistant can even send them a text message from within the app to give them a heads-up,” says Easterbrook. “They love not having to take a couple of hours out of their day for something that can take five to 10 minutes.”
Both Childs and Easterbrook use a platform out of California called doxy.me, describing it as simple to use and having end-to-end encryption.
“There are myriad solutions available, with new ones popping up all the time,” says Easterbrook. “The Doctors Technology Officer, a service of Doctors of BC, has done an initial evaluation of the major solutions and provided comments about privacy and security, features, and other capabilities.”
How it’s going in Long Term Care
Changes are taking place in long-term care facilities as well where the increase in digital or virtual technology has followed two streams: social and medical. In the social sense, the key reason is to connect isolated seniors with family.
Ian Bekker, long-term care physician lead for Island Health, says social workers and recreational therapists have been run off their feet scheduling iPad FaceTime visits and helping residents connect with family members.
“It’s a 100 per cent increase because there was zero, and now it’s super busy,” says Bekker. “It may have died down a little bit as we relaxed things slightly, but definitely there was a huge run-up.”
On the medical side, there has also been an increase.
“It was basically non-existent beforehand, so it’s become existent. It’s being used, I would say, more for the specialists,” says Bekker. “The geriatric psychiatrists, I think, are probably the biggest users of it.”
With the psychiatry appointments, which are for a set time, a nurse can set up a device and walk away to do other work. That doesn’t work so well with medical appointments.
“Now, suddenly the nurse and the doctor have to do the visit together because the nurse is participating in making the technology work, and that’s not very efficient,” says Bekker, adding that the nurses are already very busy.
That said, specialist and follow-up appointments work well with technology, and Bekker can see how it will be useful for annual family care conferences.
“The staff are adjusting, but the goal is to make things better for the patient in the end,” he says.
During lockdown, when interactions with anyone outside the care facilities was restricted, the phone was more commonly used, possibly because the video-conferencing infrastructure wasn’t as established. That may change if there is another lockdown. When long-term care facilities do use virtual technology, they employ MyVirtualVisit, Island Health’s secure video- conferencing platform. Bekker says the platform is very flexible and has been made even simpler to use.
But what Bekker is really pleased with relates to medical charts — the big binder at the nursing stations.
“When the doctors weren’t allowed to come in, and we were having these conversations on the phone, we were a little bit like, ‘Well, how am I supposed to medically, legally document this idea or that I had a conversation, I collected some information, I made a decision and these are my rationale?’ That’s what we’re supposed to be writing in the chart, but we’re not allowed to go get the chart. So Island Health and I worked to enable the physicians to do that typing in the patient’s chart at home, and then it would show up in the computer system.”
When restrictions lessened, staff continued to use the computers for charting because it was so much easier for everyone to read the notes and understand what was happening.
COVID-19 happened to coincide with the opening of The Summit, a 320-bed facility at 955 Hillside Avenue. Computer documentation was part of the plan for The Summit and all the medical staff received advance training.
“At The Summit, nurses and doctors communicate a lot more freely with the technology because it just enables better communication,” says Bekker. “We understand what’s going on with the patients a lot more.”
What’s Next?
Both Easterbrook and Childs believe — and hope — the shift to virtual care is permanent.
“It provides necessary flexibility in providing health care, and patients and physicians love having the virtual care option,” says Childs.
Easterbrook adds, “The convenience factor alone, for me and for patients, is enough to make me want to keep it.”
Childs says the challenge will be convincing patients to come for in-person visits when it is actually necessary but less convenient than a virtual visit.
“More practically, it will be the fee changes that will drive the decisions to continue to offer virtual care options,” says Childs. “If we go back to a fee difference between in-person and virtual care, it will be a challenge for family physicians to provide virtual care as a viable option long term.”
Fry notes that there are quite a few solutions in the virtual health care marketplace, and, because it was embraced so quickly, medical professionals are using different tools, depending on their region and practice, instead of one standardized system.
“Public sector leadership with the private sector partners need to look at the tools that are being used and how we can create a tool belt that is effective for clinicians and administrators to use and what can be supported,” says Fry. “I do think there’s going to be a time where they’re going to look at the number of tools in use and say, ‘Okay, what works best for our patients, what works best for our clinicians,’ and probably consolidate on a few provincial tools.”
As we look to the future, there may be more consistent stratification for types of appointments that can be virtual, saving the time and focus of physicians for complex appointments that require in-person examinations.
“Virtual care also gives the opportunity for us to expand the use of other health care professionals, whether it’s nurse practitioners or nurses or other members of the health care profession, who are very adept at conducting virtual consultations, again freeing up physicians and specialists for those in-person complex situations,” says Paish.
Fry says in 2020, in general, there was a large move to cloud technologies and, with it, concerns about privacy and whether we are ready for it. It’s a point Paish makes as well, listing issues to consider as we expand and diversify the nature of virtual consultations.
“Issues such as the protection of privacy and confidential information; the security of the systems that are being deployed; the retention and sharing of data between different systems,” says Paish. “These are all things that need to be considered as we move to virtual care being a fundamental element of the health system.”
And surely these issues will be addressed because while the pandemic pushed us forward in deploying innovative technology, it also proved how well and quickly the various sectors and organizations could work together to find solutions.
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