Virtual health care is ‘not the answer for everything,’ critics warn

TORONTO — Millions of Canadians are trying virtual health care for the first time during COVID-19 lockdowns but critics warn that it raises the risk of misdiagnosis, and could increase inappropriate prescribing and testing. Some fear it will lead to fragmented care, and could reduce health care interactions to impersonal transactions.

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.

Quality primary care is continuous, comprehensive and co-ordinated, says Aude Motulsky, an assistant professor in the School of Public Health at the University of Montreal. The idea is a family doctor knows their patients and their stories. If, under a virtual care model, the system becomes one where patients sees a different practitioner each time, quality can suffer.

“Technology is useful, but it can’t be allowed to lead to disintegrated care.”

And rather than spreading apart the practitioner and the patient, Motulsky says sometimes the solution is bringing a clinical team together in the patient’s home. That approach has had positive outcomes in France, for instance.

“Virtual care is part of the picture but it’s not the answer to everything. It should be used where needed through a national strategy that aligns it with policies that ensure standards and quality.”

PARADIGM SHIFT

When Dr. Jacqueline Bucko first heard about Lumeca a little over a year ago she thought it was an opportunity to broaden her skills, provide health care in a new way, and be part of the vanguard of new technology rolling out in Saskatchewan.

“I just thought, everything is going virtual. Why isn’t health care?”

She had no idea how fast that would change.

Pre-pandemic, a 24-hour on-call shift might mean four consults. Now she’s doing that number in an hour. The platform went from about 100 users per week at the beginning of March to more than 10 times that now, said spokesperson Tyson Liske.

“Virtual health care has been thrust from the periphery into the mainstream. You experience it once and the paradigm shifts and a light bulb comes on,” he told CTVNews.ca during a phone call from Regina.

An initial rush of calls about potential COVID-19 symptoms has subsided and has been replaced with the type of things walk-in clinics typically see, including minor injuries, prescription renewals, rashes, and abdominal pain, says Bucko, who is also a physician at a clinic in Saskatoon that specializes in women’s health.

Patients log in to the platform, answer a series of questions and are added to a virtual waiting room. They get a notification when the doctor has joined the consultation.

Patients can upload photos and Bucko says the video resolution is such that she gets a good sense of the patient’s appearance. But asking questions and gathering a patient’s history, takes on even more importance in a virtual consultation, she says.

Liske says Lumeca had been meeting with provincial health authorities for years to try to get virtual health visits covered, without success. The coronavirus changed that in weeks.

Many of the platform’s users don’t have a primary physician or face long waits for appointments, he says. It especially fills a need for remote and First Nations communities.

Right now, Bucko finds herself often reassuring frightened people that emergency departments are safe. That’s a key role, she says, because emergencies don’t stop in a pandemic.

One story that stands out was a boy of about five who had been vomiting for three to four days whenever he ate. When Bucko was finished taking his history, she felt strongly that the youngster had something stuck in his esophagus and told the parents to get him to the ER right away.

It turned out he had a toy lodged in his throat.

Meanwhile, for Judy Clark, the pandemic meant that she couldn’t be there when her 90-year-old father was treated in hospital for pneumonia in mid-April. It also meant she couldn’t take him and her mother, 91, to their family doctor for a follow-up appointment.

A conference call was a good stand-in, says Clark, who lives in Hamilton, Ont., but she wonders if a doctor can get as complete a picture during a phone call.

“I think it really depends on the doctor and how thorough they are,” she said.

“Sometimes people don’t want to admit everything that is happening with them, especially seniors. I just think it’s easier to withhold information when talking on the phone than it is when it’s face to face.”

She also worries about virtual care leaving behind seniors and others who either don’t feel comfortable with technology or can’t afford to be connected.

THE FUTURE

A CMA-Ipsos report released in August found Canadians are generally optimistic that technology will improve health care over the next 10 years, through better access and more timely and convenient care. But they have concerns about how it is implemented, with 77 per cent citing losing the human connection of health care, 75 per cent worried about their privacy, and 71 per cent concerned about opening the door to private health.

The true power of virtual care isn’t in apps and gadgets, say experts, but in reorganizing the medical system so that individuals are empowered to manage their health better, there is much greater connectivity among all points of care, comprehensive electronic health records are easily accessible for patients, and there are a range of targeted and timely solutions that give people the information and guidance they need to make good decisions.

“I think we’re at the beginning of a huge innovation cycle and health care is just entering the space that online retailing, and Airbnb and Uber, and so many others have been aggressively rolling out for a number of years,” says Dr. Ed Brown, founder and CEO of the Ontario Telemedicine Network (OTN).

Health care is more challenging because it’s public, it’s heavily regulated, and is literally about life and death. But consumers are driving the demand for choice, nonetheless.

OTN piloted a program in which about 30,000 patients could text questions to their primary care provider. Brown says 99.9 per cent of patients said they would use it again, a satisfaction level he has never seen before. And the 275 physicians involved found it to be an efficient and effective way to communicate with patients.

OTN, which became a part of the province’s new health agency Ontario Health as of April 1, now has funding to grow the program to about 1,000 physicians.

How virtual health care has stepped in and performed in this time of crisis will not only be a massive testing ground but also a source of data, research and lessons for a generation, says Brown.

“I think people are getting a pretty good feel for what it can and can’t do. Obviously, it’s not doing surgery and it’s not giving you a needle or taking your blood, but certainly for an awful lot of things, it’s not only adequate, it’s even better.”

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