Report offers recommendations for strengthening virtual care

In March 2020, the COVID-19 pandemic upended Canada’s healthcare systems,” notes health sector analyst Will Falk in a 2021 report. “In just one-month, virtual care went from 2-3% of ambulatory care visits to more than two-thirds.” While in-person visits have resumed to a great extent, virtual care is still being used far more than before the pandemic struck.

That’s because it suits the needs of patients and providers. The balanced shifted during the pandemic because of the increased need for infection control.

As one rural family physician told Falk, “Patients don’t want to come into the office. They are very resistant to that if it isn’t clinically necessary.”

His report, “The State of Virtual Care in Canada as of Wave Three of the COVID-19 Pandemic”, examines the impact of this change on patients and providers, and shows how it resulted in real, patient-centred care. The study also looks at what should be done going forward. Put another way, how do we ensure that virtual care continues to be used?

Falk interviewed over 100 people, including clinicians, academics and government officials; the study was done for Health Canada. (The full text can be accessed at: https://lnkd.in/g4YMV3Jt)

Unlike many other reports, however, Falk’s actually makes concrete recommendations. The recommendations come with a timeline, and to be honest, they’d be difficult to implement. But given the proper resources and political will, they could all be done.

Here are some of the recommendations in summary:

• Every person has the right to receive their healthcare data in a usable digital format by April 1, 2023. This should include a simple-to-administer ability to delegate control to a family member and to share information among a circle of care. Improving both public health and patient-centred care through robust health information systems.

Canada’s current health data infrastructure is still weak, threatening our communicable disease surveillance and response systems. The experience of the past year has confirmed that it is a matter of public safety that we do a better job on disease surveillance and infection control monitoring in our public health systems. A more robust data infrastructure will also improve our ability to provide excellent and well-organized virtual care to Canadians.

• Lab Requisitions and Results. We must know who is at risk of COVID-19 infection and who is immune. Patients’ results have been digitally available for decades in Canada, but through imperfect mechanisms and often not accessible to the patient. Consumer expectations changed in the last two years. They now expect their test results to be available online for at least one important test: COVID-19. All tests should now be made digital. All requisitions/results for standard lab tests should be sent/received in a usable digital format by April 1, 2023. No payment should be made for requisitions or results sent/received by paper.
• Prescriptions. All prescriptions should be sent/received digitally by April 1, 2023. Because of the crisis in opioid usage in Canada, all opioid prescriptions should be sent/received digitally by April 1, 2022. The added recommendation on opioid prescribing is long overdue and given the available services could occur immediately.
• Unlike hospitals, long-term care and home care providers often lack robust electronic record systems. A pan-Canadian healthcare organizations should work with the two major Canadian eldercare software companies to redesign institutional and home care reporting systems. Home Care: Canada now has a serious national champion in AlayaCare that allows caregivers to collect patient-reported outcome and experience measures – PROMS and PREMS. This software is built primarily as a logistics and scheduling platform and has a light health record that is focused on activities of daily living.
• Canada has the number one long-term care software system on the planet based in Mississauga. PointClickCare (PCC) employs 1,300 people in North America and is worth about US$5 billion. PCC is a huge Canadian success story and a national asset. Yet, there has been little discussion about using PCC as a reporting tool to assess quality of LTC homes and to track pandemic progress and vaccination. By current estimates, PCC already has more than 70% of the LTC market. They should be invited, among others, to co-design a standard reporting infrastructure. Note: this will require an aggressive translation program as PCC does not currently have an available French language version.
• All hospitals should provide a discharge or encounter summary to patients upon request in a usable, machine readable and searchable, digital format as of April 1, 2023. An appropriate small fee should be paid by government on behalf of requesting consumers.
• All Primary Care EMRs should provide a summary upon request in a usable, machine readable and searchable, digital format as of April 1, 2023. An appropriate small fee will be paid by government on behalf of requesting consumers.

Primary care is an excellent place to collate patients’ records and to provide a communications hub for patients about their healthcare. They have increasingly evolved from being databases and billing systems to multimodal communications systems.

Input Health (now owned by TELUS Health) and other innovative software developers have changed the game. Rather than building billing systems first, they started with communications and collection of validated information from patients. This patient-first, virtual care-first approach is being widely replicated in employer-based and on-demand virtual care. Some public healthcare systems are now also collecting automated data, as are the Ontario Virtual Care Clinic (OVCC) and 811/telehealth lines.

• A small monthly fee (Falk mentions 25 cents as an example) should be paid each month to providers as an information fee for providing a personal health record service (aka portal) that is being actively used by consumers. This fee should have a sunset period of five years as it becomes a normal part of the workflow of the health service providers (declining by 5 cents per month each year).

Current consumer access to information in Canada has relied on 20th century portal technology first developed in other countries. At last count, there were more than 90 portals in Ontario alone. Many hospitals have implemented these patient portals with mixed success during the pandemic. Separate personal records also exist in many of the healthcare segments listed above, including lab systems and pharmacies. LTC and home care provide patient summaries to family members. We have provincial immunization systems with portal like “yellow cards” that will be more important after the last two years.

Broader enrollment and use of such personal health record services should be encouraged to create an information rich system. These payments will also serve to reward players who have already started addressing this need and to encourage others to do so. The “push” recommendations above will create costs; our policy in this area should create a “pull”. A small payment of about 25 cents per active user each month ($3 per year) should be paid to each provider who has an active consumer portal.

• Canadian health information services and communications providers must publish and support usable application programming interfaces (APIs). Infoway should set tough standards for basic APIs and should have the power to enforce them.

APIs are ubiquitous in our everyday lives. Each time we pay for something with PayPal in an eCommerce store, we are using an API. When we use travel booking sites, it’s an API that aggregates thousands of flights and destinations to showcase the cheapest option. During COVID, with a proper API in place, the various vaccine scheduling systems would be able to “talk” to each, more efficiently booking second doses, and directing people to the most appropriate vaccination site.

Without an API, siloed information can still be shared by uploading information to a portal, but this is a clunky solution. APIs are a far more elegant way to do this. In a world in which foundational data elements were only created digitally, aggregating them into custom views would be the basis for competition among IT communication system providers. Said another way: in a virtual world it only makes sense that healthcare providers, labs, and others will continue to improve these products well beyond the traditional “portal”.

Patients want one place to log in that can connect them to their information on the care they received in different clinics and hospitals, summarized in plain language. That starting point will be different for various patients given their differing needs.

All patients who desire it should have same-day access to a virtual front door that connects them to the rest of the healthcare system. There are at least three ways that this should happen: provincial/regional front door, (large) group practice front door, employer-based assistance program.

Some clinicians will object to same day as unnecessarily fast for quality care. While this argument could have been credibly made before COVID, it no longer can be. Infection control and public health tracing alone require same day turnaround.

Falk’s recommendations are very ambitious but practical. His report reflects his experience as an industry insider for many years; he helped build several of our current systems and understands the complexity of the system. In short, his report sets out a bold agenda for the post-pandemic healthcare system to modernize and realize the promise of digital healthcare in Canada.