Virtual medical services are keeping many rural and remote EDs open

A growing number of rural and remote hospitals across Canada are using virtual ER physician services to cope with physician shortages and avoid ER closures, but not everyone is sold on the idea, fearing it normalizes rural inequity.

That’s not the case in Newfoundland and Labrador, where the provincial health authority contracts with Teladoc Health Canada to help staff 11 rural and remote ERs.

Newfoundland and Labrador Health Services began considering the use of virtual ER services in 2022, said Joanne Pelley, vice-president and provincial chief nursing officer. “We were at the tail end of the global pandemic, and a number of our rural and remote ER departments were experiencing staffing shortages that led to closures for hours or even days. The decision at the time was that we would look at virtual ER care as a complement to our current service delivery model to help support access across communities and more stability for our sites. We’ve had great success with virtual ER service, and our closures have gone almost to zero.”

Teladoc Health Canada is a subsidiary of New York City-based Teladoc Health, a global leader in telemedicine services. Founded in 2002, the U.S.-based company operates in more that 130 countries. In Canada, it operates virtual ER services in 14 hospitals, including sites in New Brunswick and British Columbia.

A Canadian competitor, Maple, provides virtual ER services in 12 rural hospitals in Prince Edward Island, Nova Scotia and New Brunswick. Elsewhere across the country, Alberta Health Services is operating a virtual ER pilot in four rural and remote communities and even in Toronto, a growing number of hospitals, including University Health Network, Sunnybrook Hospital and Michael Garron Hospital, offer virtual emergency services.

Virtual ER services can either supplement care to reduce wait times in hospitals with insufficient in-person ER physicians or provide care in rural and remote hospitals that would otherwise be forced to close when local physicians and locums are unavailable.

Teladoc began providing virtual ER service in Canada in 2023 and claims to have prevented more than 30,000 hours of emergency department closures in the communities it serves.

“Doctors are able to examine and treat patients working collaboratively with in-person nurses,” said Joby McKenzie, managing director, Teladoc Health Canada. “The nurse triages the patient and the doctor – through our technology – has eyes and ears on the patient as if they were there in person.”

The doctor controls the high-definition camera and can zoom in as required. Teladoc also supplies stethoscopes and otoscopes that allow the doctor to remotely listen to the patient’s breathing and examine their ears.

“All of our physicians are emergency medicine doctors located in Canada and licenced in the province where they’re practising,” said McKenzie, who claims that more than 97 percent of patients have their issue resolved as a result of the virtual ER encounter and that more than 95 percent of patients are satisfied with the service.

“That leaves approximately 3 percent of cases requiring transport to a better equipped hospital for emergency care.

Maple began offering a six-month virtual ER pilot program at Western Hospital in Alberton, PEI in 2018. That program, said Amii Stephenson, Maple’s vice-president of sales, is still in operation.

In 2022, the company contracted with Nova Scotia Health on a virtual ER pilot at the Colchester East Hants Health Centre in Truro, and that too has since been expanded to other communities.

“The goal,” she said, “is to strengthen clinical capacity, reduce patient transfers and preserve access to care in rural communities.”

Maple uses a network ER specialists and family doctors with emergency medicine experience, who connect with patients over the Internet using two-way audio and video communication technology, including stethoscopes and otoscopes.

“The vast majority of encounters in our virtual ER programs are managed onsite,” said Stephenson. In higher acuity situations, virtual ER docs stabilize patients with the assistance of in-person nurses and paramedics, and coordinate transportation as required.

Depending on how an individual program is structured, ER docs will often follow-up with patients after an encounter in the ER.

“If a patient leaves the hospital and there are still outstanding results, we absolutely follow-up,” said McKenzie. “Because we operate virtually, we don’t have the same constraints of a physical environment, so our patients are often pleasantly surprised when they hear from us at home beyond just the hours you would expect.”

Virtual ER care provides an important service for patients in rural and remote communities who might otherwise have to drive long distances to larger hospitals when their local ER is closed.

“As a parent, you may not know if your child has an acute medical condition, so when you drive up to the door of your local hospital, you need it to be open,” said McKenzie. “These emergency departments are a lifeline for the 20 percent of Canadians living in rural and remote communities.”

She added, “They pay taxes like the rest of us and deserve to have their healthcare needs supported.”

At the same time, she asserted, it’s also important that we do it in a way that’s fiscally responsible, noting that virtual ER docs can cover multiple ERs, especially during overnight shifts when volumes are low.

In addition to providing an important service for patients, virtual ER services provide lifestyle balance for overworked family doctors in rural and remote communities who are usually responsible for ER coverage.

“Virtual ER services give family doctors in these communities more control over how and when they work,” said Stephenson. “It’s essential for their well-being and retention.”

In one community Teladoc serves, a local physician was able to spend her first Christmas with her family in over five years, said McKenzie. “That means she’ll be able to stay in the community because the full burden of providing healthcare doesn’t sit on her shoulders.”

The North Shore Health Network, which serves Blind River, Thessalon and Richard’s Landing on the north shore of Lake Huron in Northern Ontario, is a good example of how physician shortages in rural and remote regions of Canada affect ER staffing. Although funded for 16.5 family physicians across the three communities, the North Shore Health Network is short eight family doctors, said president and CEO Tim Vine.

“It’s constant work to keep our ERs open,” he confided in an August interview. “Today, we’re supposed to be closed in Thessalon, but I received a text from a doctor at 7 am this morning to say they’d take the shift. We’ll be closed tomorrow because we haven’t been able to find a locum and we’ll probably be closed on Monday, but we won’t make that call until tomorrow. Currently, we have 18 uncovered shifts between all three emergency departments from today and the end of the month.”

Vine hasn’t considered virtual ER service as a possible solution and believes Ontario requires an in-person emergency medicine doctor for an emergency department to be considered open. “It would also be confusing to patients not knowing whether to come here for this, but not for that,” he worries.

In Newfoundland, it doesn’t matter if you’re having a heart attack or a case of the flu in a community served by a virtual ER service. People show up no matter what their concern is.

“We’ve managed heart attacks and multiple traumas successfully,” said Pelley. “Patients would be seen by the on-site care staff – a nurse or an advanced care paramedic. They would then have an assessment with the virtual provider and be stabilized and transported to the nearest hospital able to care for them.”