New Normal: Are virtual doctor's appointments here to stay?

New normal: Virtual health care here to stay? Virtual health care appointments are more popular than ever since the beginning of the COVID-19 pandemic, but are they here to stay?

TORONTO — When her seven-year-old son stepped on a small nail in the midst of the greatest health emergency in a century, Lindsey Longstaff decided it was the time to give virtual health care a try.

The nearest full-service emergency department was 40 minutes away in Regina and Longstaff, who has severe asthma, wanted to avoid a hospital visit. She downloaded a virtual health app, had an assessment with a nurse, uploaded some pictures of her son’s wound and within just a few minutes, received a video call from a doctor.

“It was unbelievable. I was really impressed,” Longstaff said in a phone interview with CTVNews.ca. “I thought it would feel impersonal and cold, but it didn’t feel that way at all.”

This public health emergency means that practically overnight, virtual health care in Canada has gone from the sidelines to a starring role in the health-care system. Provincial and territorial governments are not only advising practitioners to use virtual visits wherever possible, they are providing fee codes to bill for them for the first time.

Longstaff is among millions of Canadians trying virtual health care for the first time during COVID-19 lockdowns. Also referred to as telemedicine, digital health, or remote care, virtual health care is the administration of health care at a distance using technology – phone, video conference, or via live chat, text or email.

When patients themselves become the point of care it means no need to take time off work or find child care, no need to travel to an office, hospital or clinic, no parking fees, no waiting in a crowded waiting room and risking exposure to illnesses.

The idea is if more people access timely and quality care, it results in fewer ER visits, lower hospital admissions and better outcomes.

None of the technology is new and to be sure, virtual health care existed before this pandemic. But much of the uptake has been happening through private developers. Public health systems have lagged behind.

“Canada has really been delivering analogue health care in a digital world,” said Dr. Gigi Osler, who co-chaired a national, physician-led taskforce into virtual care that released its call for a Canada-wide strategy on virtual care just weeks before the pandemic hit.

Canada pioneered telemedicine more than 40 years ago to deliver health care to rural and isolated communities. Since then, adoption in the country’s public health-care system has been slow and spotty.

“2020 and COVID-19 has changed that. The pandemic is the catalyst that has introduced virtual health care to more Canadians in a matter of weeks than had been in years,” Osler, an ear, nose and throat surgeon in Winnipeg, said in an interview with CTVNews.ca.

Virtual connectivity and communication has transformed how we connect with family and friends, how we entertain ourselves, how we find dates, how we shop, bank, get information and learn. But it really hadn’t altered much about how we connect with family doctors, get prescriptions, follow-up with specialists, or seek care in urgent situations.

Now, physical distancing and stay-at-home orders are forcing unprecedented change and innovation in public medicine that experts say will revolutionize how we access care.

'A LIGHTBULB MOMENT'

In a matter of days in March, virtual visits went from a being a small fraction of health care delivery to a primary means of connecting patients to practitioners.

“We are seeing it right now as a lightbulb moment for the digital tools that have been around for years, even decades,” says Simon Hagens, who leads performance analytics at Canada Health Infoway (CHI), an independent digital health organization funded by the federal government.

“We need to demonstrate to clinicians, patients and to payers that this is a good solution. That means changing some minds.”

Neda King is convinced. She was about a month away from delivering her first child when pandemic measures meant many of her midwife appointments suddenly became virtual.

“I didn’t have a complicated pregnancy, so I was OK with phone calls,” says King, who lives in Toronto.

Since having her baby April 15, King has had a postpartum mental health assessment by phone, along with a consultation with an ER pediatrician when her infant son Carter was spitting up a lot and she couldn’t get through to her family doctor.

“I think there are a lot of things where talking to someone by phone is totally acceptable. It keeps you out of places where people are sick and it also means you don’t have to take time off work to go,” says King, who is a project co-ordinator for a construction company.

For Longstaff, her virtual visit with a doctor reassured her that her son didn’t need stitches and since his vaccinations were up to date, she didn’t need to go to emergency or a medical clinic. She was instructed how to clean and dress the wound.

“In a time that is already so stressful, to be able to avoid going into a space with a lot of sick people is a very welcome thing for our family.”

Virtual health care can’t answer the need in many situations – when sophisticated diagnostic tests need to be done, or bones need to be put in place. It can’t deliver chemotherapy, or stitch wounds, or replace a knee.

But it has a role to play in modern health-care, says Osler, a much bigger one than it had before COVID-19 changed everything.

“Let’s let virtual health care be one of the good things to come out of this pandemic.”

'TIPPING POINT'

According to CHI data, before COVID-19, between 5 and 15 per cent of primary care was happening by phone and 3 per cent by video conference. Since emergency measures were put in place, about two-thirds of visits are happening virtually.

For Dr. Ed Brown, founder and CEO of the Ontario Telemedicine Network (OTN), this is a long-awaited watershed moment.

“I've been saying for years that I thought eventually there would be more virtual care than in-person care. I'm finally right after all this time and unfortunately, it had to happen through a pandemic, but I think it was always destined to happen.”

Ubiquitous smart devices and broadly available high-speed internet connectivity, combined with an overburdened health care system, means it has long passed making sense to have to go to a doctor’s office, clinic or hospital for every health issue, Brown says.

The Deloitte Center for Health Solutions in the U.S. predicted that by 2040, “virtual health will be the near-default option for well-being and care in the future of health” in a report issued last month.

It concluded that the use of virtual care to both manage COVID-19 and continue to provide general health care could be a catalyst.

“When we look back on this outbreak 20 years from now, we might recall it as being a tipping point for how the United States and other countries respond to potential health emergencies, and a tipping point for virtual health.”

The evidence for that is growing.

OTN’s virtual system took on 16,000 applicants from mid-March until the end of April and video visits have grown from about 1,000 per day at the end February to about 14,000 a day in mid-May. That represents just a fraction of what’s happening virtually in Ontario, says Brown.

Virtual technology is remotely monitoring COVID-19 patients, and taking intensive care specialists in large centres and connecting them with smaller hospitals that don’t have that expertise. It’s delivering primary and specialty health care to remote and Indigenous communities, correctional facilities and the country’s much-beleaguered long-term care homes.

Brown says virtual care is also playing a huge role in mental health assessment, treatment and supports, a critical need in the current crisis.

Private innovators in virtual care, such as PocketPills, which calls itself Canada’s first digital pharmacy, are seeing surges in business.

Prior to the pandemic, PocketPills’ growth was fuelled by employee benefits providers looking for cost-effective solutions, says Harj Samra, a pharmacist and co-founder of the Surrey, B.C.-based company.

Now, individual consumers are seeking out contactless transactions themselves, leading to 35 per cent growth month to month, says Samra.

PocketPills dispenses the drugs into doses, and sends them for free directly to the patient’s home anywhere in Canada. PocketPills pharmacists are available by phone, text, email or chat messaging through an app and the platform automatically sends refills when it’s time for them, says Samra.

“We give people an option. They may use us all the time or just once in a while. I think what COVID-19 did was that it exposed the options that are out there from a health-care perspective. They may not have tried it otherwise for another three, five or 10 years.”

A VIRTUAL ‘GAME-CHANGER’

For Stephanie Wheaton and her three-year-old son Carter, virtual health is about much more than convenience.

At about six weeks, Carter was diagnosed with Coffin-Siris syndrome, a rare genetic condition that has resulted in him being non-mobile and non-verbal. He has a feeding tube and is on a ventilator when he sleeps.

Carter has regular appointments with about 10 specialists and a number of therapists at Children’s Hospital of Eastern Ontario in Ottawa. The family was visiting the hospital at least three times a month and all appointments were in person until pandemic restrictions were put in place.

Since then, Wheaton has consulted with doctors via phone or video call and Carter has only gone into the hospital when it’s absolutely necessary for an ultrasound, a blood test or an examination.

That is a “game-changer” for families like hers, Wheaton told CTVNews.ca.

“It's a production to get Carter there for the appointments, not to mention dealing with all the germs that are in the hospital and him being so fragile.”

Carter’s immune system is so compromised that he is admitted to hospital at least once a month during cold and flu season. With the family staying home for the last three months, it’s been the longest stretch without an admission, says Wheaton.

She is hopeful her son’s health regimen has changed forever.

“There's no reason we have to pack up everything and come into the hospital and sit in a waiting room just for a quick 10-minute appointment to check in. There's no reason it can't be done on a phone call or a video call.”

Virtual care is both a lifeline for patients and a highly efficient way to deliver care, says Carter’s pediatric neurologist Dr. Sunita Venkateswaran. Her clinic was able to connect with 35 per cent more patients in April this year than in April 2019. She says that’s because doctors can move between virtual visits more quickly and they eliminate the delays caused by late arrivers or no-shows, whether due to weather, travel issues or someone being too sick to make the visit.

Prior to the pandemic, a “very small percentage” of appointments happened virtually. That has undoubtedly permanently changed, she says. A full 94 per cent of the clinic’s April consultations were virtual.

CHEO has also implemented a virtual ER – the first at a pediatric hospital in Canada – over concerns that kids weren’t getting necessary care over fears of the pandemic.

It launched May 4, offering 24 virtual appointments a day over secure video connections.

Patient volume is still down more than 50 per cent but almost all of the virtual appointments have been filled, says emergency physician Dr. Sarah Reid.

About one-third of patients seen virtually have been told to come into the emergency department for a fuller assessment or a diagnostic investigation.

That confirms the need for the virtual portal, says Reid.

“What we were worried about were those that maybe are a little bit sicker than the parent has recognized and needed that reassurance to come into the emergency department in person.”

The most common reason children need to come is for X-rays after an injury, says Reid. That will only accelerate as the warm weather arrives and kids are out playing or riding bikes.

Other hospitals across Canada and one in the U.K. are interested in the model, says Reid. There is potential to add the service permanently, but that requires crunching some data. CHEO staff are following up with every patient family within 24 hours to document their experience.

Some of CHEO’s ER doctors were apprehensive at first, says Reid.

“It’s different. It's new, but the feedback from the physicians has been like, ‘Wow, you know, there's a lot you can do actually.’”

THE DEMAND VERSUS THE REALITY

When it comes to virtual health tools, Canada Health Infoway surveys in 2019 found big gaps between what Canadians wanted and what they were getting. While 75 per cent of Canadians wanted to book appointments electronically, just 13 per cent of family physicians were offering that option; 64 per cent said they would like to be able to email their health care provider, but just 7 per cent of family doctors were providing that; and 44 per cent wanted video visits but just 4 per cent of family doctors were doing them.

Private companies, such as Maple, Cloud DX, and Telus Health, have stepped in to fill the void. In late 2019, Maple was offering virtual consultations, prescriptions and sick notes, with a pay-per-visit fee of $49 on weekdays and $79 on weekends and holidays. Family memberships cost $50 a month. The Toronto-based company raised $14.5 million in funding in September when it reported its customer based had surpassed 400,000 thanks to partnerships with employers, group benefits providers, governments and hospitals.

It’s not that virtual care has been ignored by governments in Canada. The federal government began looking closely at it in 1997, when a national council made 39 recommendations, including the establishment of Canada Health Infoway. Since 2001, CHI has received more than $2 billion in funding from the federal government.

Last year, Ontario announced a digital-first strategy and that it had agreed to fund video patient visits on the OTN platform at the same rate as in-person visits. The government also said it planned to expand coverage to phone calls and secure messaging and care dispensed beyond the OTN platform.

The virtual care taskforce led by the Canadian Medical Association, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons called on all governments to make virtual care a priority and to establish national standards for safety, quality, privacy and access to health information.

It also recommended that governments develop fee schedules that make no distinction between health care delivered virtually and in-person, as well as embedding virtual care in medical education, professional development and accreditation standards.

Osler didn’t embrace virtual health care in her practice until about mid-March, when lockdowns required a fast shift. Since then, she has seen less than 10 per cent of her patients in person and she expects many will continue to want to stay home for visits for the duration of the pandemic and beyond.

“With this pandemic we have to realize this is an opportunity for meaningful change in the health-care system.”

VIRTUALLY AT HOME

Hamilton, Ont. family physician Dr. Rick Tytus routinely makes virtual house calls.

They began about three years ago when he found some patients with mobility issues or heart or respiratory conditions weren’t able to come to his office for appointments. Hoping to avoid seeing his patients end up in emergency rooms, Tytus began sending a staff member to their homes to assess their health. He then checks in via video call from his office.

He wasn’t getting paid for those virtual check-ups, until COVID-19 struck, that is.

“I really think the genie has left the bottle. There is no going back,” Tytus told CTVNews.ca. “Virtual health is here to stay.”

He says seeing patients in their homes provides a fuller picture of their health than in-office appointments. His staff take note of how people are eating, whether they are taking their medications, and how safe their home is, and if there is a concern, Tytus alerts other health practitioners, including social workers or occupational therapists.

“I tell people that it’s better than face-to-face when you’ve got an 85-year-old in a wheelchair and they’ve got to get bundled into the car, come to the office, wait in a crowded waiting room and by the time they are in to see me, it’s already been a two-hour ordeal for them. Now their blood pressure is crazy and we wonder why.”

Tytus doesn’t know of other family doctors doing what he’s doing, but he points out that home health care kits are available in the U.S. for several hundred dollars that include a video screen and Bluetooth-enabled stethoscope and otoscope to look inside ears.

“There will come a time when a doctor sees you virtually and directs you to use the equipment so they can assess you. This is not a pipedream. It’s all here.”

New Normal is a CTVNews.ca series looking at how life will change in the wake of the COVID-19 pandemic.

Edited by Senior Producer Mary Nersessian