Telemedicine networks are significant tools supporting clinicians in remote areas

On the heels of a nationwide acceleration of virtual care sparked by the pandemic, patients and clinicians in rural, remote and Indigenous B.C. communities are finding that accessing healthcare services or peer support can be as easy and comfortable as calling a friend.

“We’re breaking down barriers,” said Dr. John Pawlovich, a rural family doctor and virtual health lead at the Rural Coordination Centre of B.C. “Clinicians, nurses and doctors new to practice in remote areas are really feeling that comfort in reaching out for help. They’re not hesitating, they’re not feeling ambivalent … they’re actually feeling really comfortable and motivated to call because it’s a good experience when they do.”

At the same time, community members who haven’t sought medical assistance in years are starting to rekindle relationships with healthcare providers over the phone or on Zoom video calls. “They feel listened to and cared for,” said Dr. Terri Aldred, medical director of Primary Care at the First Nations Health Authority (FNHA). “They were waiting in limbo and unsure how to navigate the system and suddenly it seems that things are moving really quickly.”

Both doctors are referring to the ongoing success of the province’s Real-Time Virtual Support (RTVS) initiative, a free service launched in April 2020 to quickly provide healthcare services to rural, remote and Indigenous citizens, and to support the healthcare practitioners serving in their communities at a time when lockdowns were exacerbating existing inequities in care. One year later, the project is fully operationalized and funded as it continues to grow at a significant pace, adding both capacity and programming.

Led by The Virtual Health and Wellness Collaborative for Rural and First Nations B.C., a collaborative that brings together multiple stakeholders including the Rural Coordination Centre, First Nations Health Authority, Provincial Health Services Authority, Providence Health Care, B.C. Emergency Medicine Network and UBC Department of Emergency Medicine, RTVS builds on years of work to bridge the access to care gap in the province. What sets the initiative apart from other attempts to address inequity in healthcare is the foundational belief that the solution must be community led and culturally safe to ensure people feel empowered to make decisions that are right for them, whether they are patients seeking medical attention or clinicians seeking peer support.

“First and foremost, this is a story of people and then it’s about how technology can support the communication and the relationships between the people who are involved,” said Dr. Pawlovich, noting that the quick rollout of RTVS wouldn’t have been possible without the preparatory work of the collaborative.

RTVS currently offers three patient-facing pathways and four peer-to-peer pathways, primarily supported by video or phone calls, and in some cases by mobile apps. On the peer-to-peer side, pathways are designed to support the province’s most remote and vulnerable “edge” communities where the only healthcare resource may be a nursing station.

The goal is to respond to requests for help within seconds, answering with a friendly ‘How can I help?’ as opposed to ‘Why are you calling me? I’m busy.’

“What happens in historical interactions is the vulnerable doctor in a remote site reaches out to a larger centre looking for help and often times that person in the larger centre, through no fault of their own, is simply too heavily immersed in what they’re doing and can’t be all-in on the call,” explained Dr. Pawlovich.

In their first year, the peer-to-peer pathways – which provide pediatrics, maternity and newborn, critical care and emergency medicine support 24 hours a day, seven days a week – saw a combined 230 percent increase in calls, with 91 different communities accessing at least one peer-to-peer pathway for support.

The on-demand sessions last anywhere from five minutes to five hours or longer and the pool of roughly 200 specialists and physicians who staff the service are dedicated to their shifts to ensure a rapid response time.

The medical problems supported range from head injuries, seizures, and fractures to cardiac arrests, COVID-19 intubations and life-threatening issues, to infants with ring worm, inconsolable crying or a foreign body in the ear.

Most sessions occur over Zoom, but the team is starting to advance their understanding of how technology can further improve peer support in remote communities. Some of the leading-edge technologies being explored include smart glasses, point-of-care ultrasound and the ability to run computer simulations for educational purposes.

“Our virtual team wraps itself around these communities to be what they need us to be,” said Dr. Pawlovich, noting that all pathways are created and led by people with deep rural knowledge and experience. “It could be helping with transport, managing a patient, or simply settling everybody down and being a friend. It’s really that ‘call a friend’ philosophy that we predicate our RTVS philosophy on and I think that’s starting to be transformative.”

On the patient-facing side of RTVS, two pathways are being led by the FNHA – the First Nations Virtual Doctor of the Day and First Nations Virtual Substance Use and Psychiatry Service – and a third pathway adds virtual consultations to the province’s standard telephone-based 811 nursing services.

Megan Hunt, FNHA acting executive director of Primary Healthcare and eHealth, said the service delivery model for both the Doctor of the Day and Substance Use and Psychiatry programs is based on a “shared care approach” where traditional wellness providers or sacred knowledge keepers work alongside western health and wellness professionals.

Virtual sessions are supported by a single instance electronic medical record so that all practitioners work from the same information, meaning a patient doesn’t need to repeat their story multiple times as they move between providers.

Both pathways are designed to be “low barrier,” she added. Instead of travelling to a health centre to see a provider on a specific day, for example, community members access services from phone (landline, satellite or smartphone), tablet or laptop from the comfort of home, depending on the level of connectivity available in their community.

Referrals for addiction medicine can be made by any provider, not just a primary care physician, and virtual services are offered in a “safe space framework” designed to reach individuals who are struggling with mental health or addiction issues, whose behaviour often causes them to be denied services in the broader health system.

“Rather than saying to patients, ‘You’re fired from this program,’ which happens across the health system all of the time … our safe space framework provides the opportunity for myself and our medical director to reach in and have a conversation with the individual,” explained Hunt. “We hear their perspective and see if there’s a way to move forward with common understandings and expectations about how we can do that.”

The number of people accessing the patient-facing pathways is steadily increasing month over month, and users report a high rate of satisfaction following their virtual encounters. Hunt credits the success to the fact that the delivery model was “developed and operationalized by and with First Nations people” and applies a very specific screening and selection process when enrolling providers.

“We’re really looking for practitioners who are curious about learning about themselves, who see it as a mutual relationship, not an ownership relationship, who participate in First Nations culture and participate with community,” she said, noting that a significant number of physicians staffing the virtual programs are of Indigenous ancestry.

The First Nations Virtual Doctor of the Day program is staffed from 8:30 to 4:30 every day of the year, including holidays. Four doctors are always available, one for each geographic region, and the goal is to provide same day care.

As one of the providers on the service, Dr. Aldred sees firsthand the tangible benefit of reaching people who are unattached to care. She said the web-based pathway is easy to set up and use, and that she appreciates the support of medical office assistants, the first to greet and triage patients who call in, and care coordinators, who manage the circle of care for patients, connecting them to community resources as needed.

She believes the upfront work to ensure the right physicians are onboarded to the virtual service, including asking them to provide a statement about what cultural safety means to them and asking them to reflect on privilege, is important.

“I’m Indigenous. I’ve been involved in cultural safety work and anti-racism work pretty much since the day I walked into med school, and I still learn,” she said. “We have the processes that we do because that’s what our community asks for. They want to see providers who are kind, who are going to spend time with them, and who genuinely care, so the onus is on us to recruit people who are going to uphold those principles and stand behind them.”

Maple Maskawâhtik, a joint venture by telemedicine provider Maple and Saa Dene Group, a collective of Indigenous-owned companies, is another virtual platform working to expand access to essential services where they’re needed most across Canada.

“Our goal in forming this venture was to focus on increasing access to rural, remote and Indigenous people across Canada using culturally appropriate care and digital means,” said Maple vice-president, Business Development, Christy Prada. Just nine months after launching in December 2020, Maple Maskawâhtik, named after the Cree word for maple, is “heading in the right direction and on the precipice of scaling,” she said. The focus to date is on finding government and business partners to help advance the program.

Saa Dene president and founder Jim Boucher, a First Nations chief for more than three decades and Saa Dene CEO Jauvonne Kitto, a former First Nations health director, bring firsthand experience and knowledge of healthcare access issues to the venture. Maple brings the virtual care platform and the expertise to tailor the technology to support community-based models of care.

“It’s not about going in and saying, ‘Here’s the care, take it.’ It’s about working with those groups to understand their needs, their challenges, and the population health issues that affect them specifically and how they want to solve it,” said Prada.

The approach includes training and socializing providers in the Maple Maskawâhtik network to foster cultural sensitivity, as well as broadening provider types available on the platform to include healers, medicine men, sacred knowledge keepers, elders and others, depending on community-specific needs.

Maple Maskawâhtik is currently working with several communities across Canada and is also partnering with leading 5G telecommunications providers to address connectivity concerns in remote areas.

Recently, the venture partnered with the Alberta government to launch an alternative relationship plan (ARP) program, allowing them to offer virtual care on a publicly funded basis to all Albertans.

“Our goal is to grow this ARP with a focus on rural and remote communities and helping patients who are unattached … who don’t have a family physician or reliable means of care,” said Prada, calling the ARP a critical first step. “The technology will allow us to enhance access in those communities and not only bring access to physicians, but make sure that we’re looping in culturally appropriate care.”

In her former role as health director, Kitto witnessed healthcare inequity firsthand. Doctor services were only provided a few days per week in her community and when specialty services were required, people had to travel six hours or more.

“I believe that an individual should have a choice of who they wish to see, when they wish to see them and where, and virtual care enables that,” said Kitto, noting that Maple Maskawâhtik will offer specialized cultural healing as well. At the same time, she recognizes that the inequity issue is not only affecting Indigenous peoples but all people living in rural and remote Canadian communities.

“Maple Maskawâhtik is a true form of collaboration and continuity of care,” she added. “It is Indigenous owned and led, so we understand the culturally appropriate care model, but we also don’t want to limit it to one demographic of people.”