‘I know that it saved my life’: Can virtual health care ease Canada’s ER crisis?

It started as headaches, nausea and feelings of pressure in his head – things most people attribute to stress, dehydration or a simple virus.

But when Dylan Harris started briefly losing his eyesight three months ago every time he coughed or sneezed after months of debilitating pain in his head, he knew he needed to see a doctor.

The problem was, the then-Newfoundland and Labrador resident didn’t have a doctor.

Harris had been on a waiting list for a family doctor since moving to Canada’s easternmost province three years prior.

With no other options available, he tried visiting local hospital emergency departments, on multiple occasions. But each time, the wait was so long, he eventually left without treatment.

“In my own mind, I was too sick to be there. I was falling down. I was throwing up. I had an intense headache. I was just tilted over asleep in one of the waiting room chairs,” he recalls. “I just told my wife to take me home where I can lay down and be in pain in my own bed.”

Finally, his wife suggested he try seeing a physician virtually.

He was able to quickly book an appointment – the cost of which was covered by the province – and, after a 10-minute online video conversation, Harris had a CT scan booked.

Wait times for diagnostic imaging are lengthy across the country, so he had to wait at least two months for the scan, but within hours of leaving the CT the appointment, the virtual-care physician was calling him. Harris had a mass on his cerebellum that needed to come out right away.

“That was the scariest point of my life,” Harris recalls.

He believes being able to access virtual health care saved his life. The mass turned out to be benign, but the side effects it was having on his ability to perform simple functions were severe.

“There were points leading up to the days before the scan and getting the actual surgery where I’d be driving to work on the highway and I’d have one of these sneezing, coughing fits and I couldn’t see for three-to-five seconds,” he said.

“I don’t know if I’d be here if I didn’t if I didn’t receive the virtual care that I did … I know that it saved my life.”

Virtual care is one of many innovations in health care that experts and health authorities have been studying and trying out in baby steps for a number of years, but the COVID-19 pandemic vastly accelerated both the opportunities and challenges of this emerging field of medicine.

Now, in the wake of what many are calling a “crisis” in Canada’s health system due to nation-wide shortages of health workers, ongoing waves of COVID-19 infection and cascading ER closures in hospitals across the country, virtual care is increasingly being eyed as a solution to fill some gaps in the health system.

Already, more Canadians than ever have been seeing doctors virtually, according to information published in June 2021 by Canada Health Infoway.

It found virtual care use in Canada rose from between 10 and 20 per cent in 2019 to 60 per cent of all health care visits in April 2020, although that number dropped to 33 per cent by March 2022.

The Canadian Institute for Health Information (CIHI) also released data showing that, in February 2020, for the provinces where data were available, 48 per cent of physicians had provided at least one virtual care service. By September 2020, this number had increased to 83 per cent.

The number of patients accessing virtual care has also significantly increased.

In 2019, virtual care accounted for between two and 11 per cent of services that patients received, depending on the province, according to the CIHI. One year later, patients in Ontario, Manitoba, Saskatchewan, Alberta and British Columbia received between 24 per cent and 42 per cent of their health services virtually and an average of 16 per cent of the population of these five provinces received one or more virtual health services per month, CIHI data shows.

As for what health care services are available to patients in Canada virtually, it varies widely, depending on the province or region. Even the term “virtual care” can encompass a variety of mediums, including receiving care from a physician via telephone consultation, through videoconferencing or getting prescriptions or medical paperwork through email or secure electronic messaging.

When it comes to seeing a physician virtually, there are a number of different platforms, many of which are operated by for-profit companies, such as Telus Health, Maple, Babylon, Tia Health and Rocket Doctor. These companies contract licensed physicians to see patients in a kind of online walk-in clinic.

Patients who use these services are first assessed to ensure they are appropriate for virtual care, and are then usually able to see a doctor virtually more quickly than if they visited an in-person walk-in clinic or emergency department.

Dr. William Cherniak, an emergency physician and CEO of Rocket Doctor, says he believes his platform provides an opportunity for the nearly five million Canadians who do not have a family doctor (according to Statistics Canada) to receive the care they need without clogging up emergency rooms already overwhelmed with too many patients and not enough staff.

“A lot of patients who come to an ER don’t actually need emergency services, they need family physicians or outpatient care,” Cherniak said.

“Of the patients we’ve seen so far, 92 per cent have been effectively managed virtually, and only that eight per cent have been sent actually back to the (emergency) department or an in-person (service) and usually it’s a specialist referral.”

Virtual care also provides more opportunities for patients who live in rural or remote areas of Canada to access doctors who prefer to live and practice in larger, better-resourced health networks.

This creates opportunities to set up specialized services in communities and populations that are often underserved, Cherniak said.

“We have a partnership with a homeless shelter in Timmins, where we’re providing virtual addictions and medicine services, we’ve got a program set up now where the team has seen more than a thousand patients for free, using their OHIP (Ontario Health Insurance Plan) to help folks get off of opiates, alcohol, amphetamines, smoking,” he said.

“Virtual care – like anything in medicine or in life – will take time to refine and get better and integrate better with the current system so it’s not these parallel streams, but as they get integrated and meshed together, I think it offers huge potential to help.”

But while virtual care provides a number of opportunities for patients and physicians alike, it also raises a number of questions about access – in particular when it comes to payment.

Most private virtual care companies prefer their services to be covered by provincial health plans, where patients simply provide their health card number and the province is billed for the appointment. And most do have agreements with some provinces to operate as publicly-funded services, including Rocket Doctor.

However, every province has different rules and regulations when it comes to virtual care and how it is covered. Many of these rules are changing rapidly in each province, which is making it challenging for platforms like Cherniak’s to expand and be more widely available.

Dr. Brett Belchetz is the CEO and co-founder of the virtual health platform Maple, which is available across the country. He said he is concerned about more restrictive rules being adopted around virtual care across Canada, pointing specifically to a new physician services agreement in Ontario that takes effect next month, which he says will “significantly reduce” what the province will pay doctors to virtually treat patients they haven’t seen before in person.

“Certainly when we look at those (Ontario) billing changes, there will be no way for the doctors who are helping those patients, particularly patients who are in rural locations, to see them physically in order to be able to bill properly for treating those patients virtually,” Belchetz said.

“So we’re going to see some real challenges in access to care virtually emerge as a result of that. And we’re seeing similar changes that occur across the country.”

Another barrier in the rollout of virtual care is that most provinces and territories have rules that say physicians cannot treat a patient virtually unless they are licensed in the province in which the patient resides, Belchetz said. That means in places where doctors are already in short supply, such as rural and remote regions, virtual care is less accessible as in other parts of Canada.

It’s why many doctors and their advocates, including the Canadian Medical Association (CMA), are calling for pan-Canadian licensure of physicians. This would allow them to practice virtually or in-person in any province or territory without having to go through the hassle and expense of becoming licensed to practice in each province and territory.

“In this day and age, it certainly doesn’t make a lot of sense that we require doctors to have 13 different licences if they’re going to treat across the country,” Belchetz said.

“We’re actually cutting off potential capacity solutions in our system.”

As for concerns that have been raised that virtual care could take the limited number of physicians in Canada out of hospitals and in-person practices, both Cherniak and Belchetz say their platforms have been designed so doctors can use virtual care as an addition to their physical practices.

Belchetz describes Maple as an “Uber-like” platform that allows doctors to jump onto the application when they have free time. He says the “vast majority” of physicians using Maple take virtual appointments in between in-person patients or during unexpected free periods of time. For example, a family doctor may use the half-hour they’re waiting to pick their child up from ballet practice to see a patient or two.

“We’ve been able to allow doctors to actually use a lot of the hours of their day that were previously unusable for patient care, to open up patient care.”

He added that most physicians using the platform report they have not shut down their practices, but rather are expanding the hours they are seeing patients when it works for their lifestyles.

“We’re opening up capacity where no capacity existed before,” Belchetz said.

Concerns remain about a number of factors when it comes to virtual health care, including equity of access, given the growth of services available outside the publicly-funded system, according to a national Virtual Care Task Force, formed in 2019 by the CMA, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada.

The task force also identified a number of key concerns regarding electronic medical records, including that privacy and data governance rules are different in many provinces and territories, which makes interoperability of medical records between jurisdictions challenging.

There is also concern about a market consolidation of medical records in Canada among a small number of private companies and that there are no national regulations dictating how they should be treating or sharing these records.

This prompted a market study by the Competition Bureau of Canada, which noted the majority of health-care providers use an electronic medical record system owned by one of just three companies in Canada.

“Accessing and sharing information from those systems is often difficult. As a result, much of Canadians’ personal health information is locked inside the systems of a small number of companies,” the Competition Bureau said in a report published in June.

The CMA also raised this as a concern, noting in a June 2021 submission to the Competition Bureau it had “heard anecdotally about several cases where physicians/application developers were facing large charges to access electronic patient data for quality improvement and related purposes.”

The Competition Bureau recommended that Canada’s privacy and data governance rules for electronic medical records be harmonized in Canada and called for the companies that currently hold these records to comply with “anti-blocking” rules to ensure fair access, even suggesting that an independent organization be established to enforce these rules.

But not all virtual health care services are operating in the private sector.

In Ontario, a project with the University Health Network (UHN) began in late 2020 that saw a “virtual ER” opened to patients in that province where patients with non-life-threatening conditions can see a doctor online, either through video or audio depending on the nature of the complaint.

Dr. Sameer Masood, an ER physician at UHN and the lead physician for the virtual ER, says he believes the project has been a success, with more than 2,000 patients seen over the last two years – patients that otherwise would have gone to hospital ERs that have been struggling with overcapacity and staffing issues.

Masood says he believes offering virtual care through the public health system is superior to private options because it allows more of a continuum of care. Patients who first see a doctor virtually at UHN may need in-person follow-up and can be directly referred to the local hospital, which can be apprised of the situation and ready for that patient when they arrive, he said. Alternatively, in-person patients can also be referred to virtual care for follow-up, he added.

“So, unlike, for example, a lot of other virtual walk-in clinics where there is no connection between them virtually and a physical entity, we have a seamless transition between the virtual ER and the in-person ER,” Masood said.

While virtual care provides a new and more accessible way for patients to receive medical care, Masood echoed warnings by the CMA and the Virtual Care Task Force that it is not a panacea to the many challenges facing Canada’s health system.

Both the CMA and the task force have strongly emphasized that not all patients or conditions should be treated through virtual care, and they warn that moving too quickly away from in-person care in favour of online options could “undermine continuity of care” and could also lead to inappropriate use of health-care resources, such as the ordering of unnecessary additional tests.

But the traditional public health system must also be willing to adopt – and fund – virtual care, because it’s here to stay, Masood said.

“The backbone of our health-care system, the backbone of patient care is primary care and is a coordinated system,” he said.

“If we don’t incorporate virtual care into that, it’s going to be problematic. So, I think we have to ensure that it’s part of a continuous care pathway for patients and one of the many options available to patients and not the only option available to patients.”