Virtual Care in Canada — Dr. Ewan Affleck

Avis Favaro

Canadians welcomed virtual medicine when COVID pushed much of the country onto our phones or computers for basic health care.
Data shows the number of people who received virtual services quadrupled during the pandemic compared to before, and that’s no surprise to doctors like Ewan Affleck, who has championed a shift to digital medicine for 3 decades.

Dr. Ewan Affleck

Canadians wanted the capacity to access care virtually for many, many years. And despite that, we were exceedingly slow to adopt this. And in fact, it took a virus to prompt change, but that demand was not new. It’s just suddenly we had no choice.

Avis Favaro

Dr. Affleck is a family doctor who works in Yellowknife and in Edmonton, where he’s chair of Alberta’s Virtual Care Coordinating Body. He also received the Order of Canada after helping the Northwest Territories become the first health system in the country to create an online patient chart system, so that doctors and nurses caring for that patient can all see the same chart.
His goal now is to coax the rest of Canadian health care away from paper charts and faxes to modern virtual and digital health care because it’s faster and safer for doctors and patients.

Dr. Ewan Affleck

If for some reason I’m missing some of that information, or it is inaccessible, or I do not know it exists, whatever reason, because it’s on a different platform and I can’t see it, the likelihood of my making an error increases.

Avis Favaro

Hello, and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.
A note: Opinions expressed here don’t necessarily reflect those of CIHI, but this is a free and open discussion. And this show is about CIHI’s expansion of virtual care report. Canadians wanted it. We finally got some more virtual health care, but not the full digital health transformation seen in other countries. Why is that and what comes next?
Welcome, Dr. Affleck. Nice to see you.

Dr. Ewan Affleck

Thank you very much, Avis. Nice to be here.

Avis Favaro

And you are in Yellowknife right now?

Dr. Ewan Affleck

No, I’m in Edmonton.

Avis Favaro

Oh, you’re back in Edmonton.

Dr. Ewan Affleck

I was in Yellowknife a few days ago. I go back and forth.

Avis Favaro

Right. I was interested. Before we get into virtual medicine, what is it that drew you to Canada’s north? And was medicine there something that twigged your interest in virtual care?

Dr. Ewan Affleck

I think love did, probably, had something to do with it. My wife —

Avis Favaro

Love?

Dr. Ewan Affleck

Yes, love. Maybe not what you were expecting. But I think it’s a good answer. My wife was from Labrador. And when we got together, she was doing a degree. We were both doing degrees at McGill. And she said, let’s go back up north. And so we did. And it became a life. We raised our children and have been all over Canada’s north.

Avis Favaro

That’s wonderful. Is that where you started to see the disparities in health care and what role virtual care might play?

Dr. Ewan Affleck

Absolutely. I graduated from McGill in 1992 from the residency program. And my first job was in Arctic Quebec and Nunavik on the Hudson Strait. I was placed in a little community called Salluit. And I was terrified as physicians can be, or health care workers, and certainly a new grad dealing with some situations. I was all alone. I was the only physician in the community. And there were times that I wanted to be able to share either images or data or information of some sort with experts in another location. And largely, I was unable to do so.
And so I would dream of how to do this. And it became clear to me quite rapidly that the people in these remote locations suffer from inequities in care because they do not have access to that expertise or the capacity that people in perhaps some larger centres do. So that was the genesis of my interest in this. And this was 31 years ago.

Avis Favaro

Wow. So this has been a project for you for 3 decades then.

Dr. Ewan Affleck

It has. I have dedicated much of my career to this, yes.

Avis Favaro

So the concept of virtual care — I remember talking about it long before the pandemic in terms of talking about new start-up companies, private companies that were offering the vision of virtual care where you could see your doctor. How were we doing as a country with virtual care before the pandemic?

Dr. Ewan Affleck

Canadians wanted the capacity to access care virtually for many, many years. And despite that, we were exceedingly slow to adopt this. And in fact, it took a virus to prompt a change, but that demand was not new. It’s just suddenly we had no choice.
So for me, the interesting question is not that we were able to adapt, because we really had no choice, but why we did not address this before in any systematic or systemic way.

Avis Favaro

Private companies could see the demand and they could see people wanted it, but the rest of the system did not.

Dr. Ewan Affleck

It spoke to the cumbersome nature of public health care in Canada, that we were unable to get our heads around the adaptation to virtualized services. For me, it’s a profoundly important question. And it actually frames a lot of our approach and the challenges we face with digital health, is why we seem to have trouble adapting to these new means of care.

Avis Favaro

So let’s take a look at the latest CIHI data.
There was a report. Previous data has shown that we went from 1% to 10% or 11% of people using virtual care, in the sense of seeing their physician or having something done by phone or video, to like half of Canadians. And then the report now, to me, seems to indicate that different provinces are doing different things, there’s a bit of a hodgepodge of things.

You’ve read the report. What does it tell you about where things stand in terms of virtual care in Canada?

Dr. Ewan Affleck

Largely, the form of technology or the service that was most readily available to us was the telephone. And this is because it’s ubiquitous. It is well understood by both the provider and the beneficiary of care, the patient. You can just phone anyone from a phone and you don’t even know who is running the technology for the most part. You don’t think, oh, this is this provider or that provider.

This was not a technology that was deployed by the health care system. It’s a technology we use that other people have deployed. So, in fact, the technologies that we have had to engage with, videoconferencing, secure messaging and remote monitoring, and other such technologies, have been far less successful.

Avis Favaro

Wow. Here I was thinking we did pretty well, but what you’re saying is we underperformed. We really just did phone calls. So are you saying we didn’t do as well as we think we did?

Dr. Ewan Affleck

If you look at mature environments like Kaiser Permanente in the United States, they have an integrated service with a variety of forms of virtualized care, so different technologies such as phone or voice and video and text-based virtualization. And you can see through their data that they are integrating these in a more wholesome way, as opposed to in Canada where we largely simply engaged with 1 principal technology. But as a system, as an overall offering, most of the transition to virtualization was done through the phone.

And so I don’t want people — which is great. The phone is a wonderful virtual tool, but I don’t want people to imagine that we engaged with all aspects of virtual care. In fact, we did not do so meaningfully in some cases.

Avis Favaro

That’s pretty interesting. So what else did you get from the report in terms of what different areas are doing? Were there any messages there?

Dr. Ewan Affleck

Yeah, what the report suggests is things are not coordinated at all. So the first thing is that we need definitional rigour. So if you think of this, and this is what came out in the Pan-Canadian Health Data Strategy Report recently, is that we should design digital systems around patients, or the beneficiaries of care, or citizens. And this is not a hard idea to get your head around.

If your health information, Avis, doesn’t follow you, wherever you may be, then you’re at risk of errors being made. Right? It is yours, and it should follow you, and you never quite know when you’ll need it. And it should go to the nurses, doctors, pharmacists, whomever are caring for you, your circle of care, in order to assure that your health and the quality of your health care is maximized.

So what always jumps out at one in these things is we then have a fragmented approach where different jurisdictions and different locations are doing different things, rather than saying we need to harmonize our approach around Canadian citizens.

And in fact, we would all benefit. In fact, it would benefit governments. Doing things 13 times doesn’t make much sense, but it also successfully fragments our approach. And in the report, Newfoundland says this. I think we need to do this. We need a harmonized approach based on standards, and they call that out. I didn’t see that from others, but that has not been our tradition, and it’s a very expensive and costly mistake.

Avis Favaro

I know that you got an Order of Canada for doing work in the Northwest Territories and bringing electronic medical records in some form there. Are they doing it right? Where can you show us an example of what the rest of the country could follow?

Dr. Ewan Affleck

Well, I think there are many instances of excellence. The Northwest Territories built 1 single chart that is basically designed around the patient. It’s the exchange of information between people that are remote from each other, either the patient or anyone in their circle of care, using any form of technology for the promotion of quality care. So that’s the definition.

So if you’re sitting in Uluhaktok or Gamèti or Whatì or Yellowknife or Hay River you are using the same chart. So if you’re travelling around, all your information follows you wherever you may be. And in fact, all the different health care providers can communicate with each other through your chart.

And this was noted in the report that we lag compared to other, you know, the Commonwealth report; we lag compared to other Western industrialized nations. But in fact, that works well in the Northwest Territories.

Avis Favaro

Yes, and that’s one of the points in the CIHI report, comparing Canada to other Commonwealth countries. We saw a bit of an up-tick in transferring patient data to other offices, and more practices seem to offer patients options to communicate by email or secure websites, or even see their data online in 2022 compared to 2019 in the report. But all of these areas remained below the Commonwealth country report average.

So, Dr. Affleck, can you go over the benefits to doctor and patient of doing more of what happens in the Northwest Territories, which seems like it’s more like what’s being done in Commonwealth countries?

Dr. Ewan Affleck

You create the network effect, meaning the entire circle of care. So if you were there, Avis, your entire circle of care can see your information wherever you might happen to be and wherever you might happen to require care, as opposed to what we’ve largely done in Canada is not created networks, but created relational virtual care. So you can communicate perhaps with your physician, but you can’t communicate — your physiotherapist or your social worker or your orthopedic surgeon are on a different system. There is not a network.

So we have separated information by service or custodian largely. So we have not built the information around the beneficiary of care, the patient. That is what happened with the single chart in the Northwest Territories. It is happening at AHS in Alberta with Connect Care within the specialty sort of services.

So it’s a component of the service in Alberta and there are other instances, but this is not the norm in Canada.

Avis Favaro

No. And a lot of the information is passed on by faxes.

Dr. Ewan Affleck

Yes. Because you don’t communicate, or you haven’t created the network effect around an individual’s information, you then have to find other means to transfer it to these other sources. So we haven’t created an integrated system, and this really struck me in the report. They state interoperability, or lack thereof, is a huge problem.

Avis Favaro

Meaning, interoperability for people who may not know?

Dr. Ewan Affleck

It means data interoperability. So your data will be able to go, as I said, from one service to another, depending on your health needs. So what we’ve done is we’ve adopted technologies that are not interoperable. They’re not — no common data standards, so patients’ information can’t move. So then you have to use a fax machine or something.

Avis Favaro

How antiquated is that?

Dr. Ewan Affleck

Totally. So digital systems don’t talk to each other.

So in the United States, in 2016, they enacted something called the 21st Century Cures Act, and they are then rolling this out. And it’s basically that different digital platforms must be interoperable, meaning your health information can move from one service provider to another.

There is no jurisdiction in Canada that has done that. And despite the fact that this report says this is a big problem, I did not see in any of the strategies anyone addressing this in any way. So it seems counterintuitive.

And I know it’s beginning to happen in Canada, but it is a huge problem that we do not demand interoperable health data in our ecosystem, and it’s simply not acceptable anymore.

Avis Favaro

So really, as a patient, we should all have the right to have our data available to anyone who needs it whenever they need it.

Dr. Ewan Affleck

Absolutely. The privacy laws and health information acts allow for that to occur, but there are many other factors at play that impair that currently, technical and otherwise.

Avis Favaro

Well, let’s talk about the cost to patients of not having this.

Dr. Ewan Affleck

So every decision that is made in health care about your health, or mine, or anyone’s, is based on the gathering and analysis of information. It’s an information industry.

So I was on call last week and I’m looking at laboratory reports; I’m looking at X-rays; I’m talking to a specialist, perhaps; I’m talking to the family or the patient. And I’m gathering all this information and I’m then crafting an approach to the care for that individual.

If, for some reason, I’m missing some of that information, or it is inaccessible, or I do not know it exists, for whatever reason, because it’s on a different platform and I can’t see it, the likelihood of my making an error increases. And so it is essential that the information that is required by individuals to make decisions is available to them in order to preserve the quality of care of patients.

And the same goes for populations. If we can pool that data, we can have greater insights into how to manage COVID, studying a response to new therapies for cancers. But the more it’s fragmented and doesn’t talk to each other, then the challenges we have with pooling it, or aggregating it, will impair our capacity. So this has a negative impact on people’s health.

Avis Favaro

Do you see examples where patients pay the price of not having connected digital health care?

Dr. Ewan Affleck

Absolutely. There is an important case in Canada. It’s probably the best known and it is in the public domain. This is a gentleman named Greg Price who died 11 years ago. The first cause of death is ascribed to mismanagement of his information.

So over the course of 407 days and 12 different health services, his information kept being lost because it was faxed or someone had shut an office or this or that. And basically he had a small cancer and 407 days later died of a pulmonary embolus, none of which needed to happen if his care had been expedited and the errors, informational errors, had not occurred.

Avis Favaro

That was a decade ago. It surely can’t be happening now.

Dr. Ewan Affleck

If you ask the question, who is looking for informational errors as a cause of poor patient outcomes, it’s not really being evaluated. Number 1. Number 2, I would suggest it is happening. So you have to be very careful and it’s stressful.

And I don’t want to be alarmist, but it’s important. I mean, we require information to make decisions and if it is not available, or missing, we can make errors. And that’s a concern.

And so we have to design systems that are safe for people and are efficient and effective and equitable and so forth.

Avis Favaro

Now, the CIHI report does show that more Canadian family doctors were using electronic medical records in 2022 compared to 2015, and they were using more remote monitoring. That’s where they check patients’ conditions like blood pressure remotely so they don’t have to come into the office for these tests.

So, Dr. Affleck, what are some examples of successes of using virtual care in its entirety? Who does it right?

Dr. Ewan Affleck

Virtually every province and territory has excellent instances of virtualized services that are quite successful. The challenge we have is one more of scaling and spreading that, those initiatives.

Avis Favaro

Making it national.

Dr. Ewan Affleck

Because there’s no harmonized — yeah, national or even provincial. And because what we lack, and it’s actually — and it was compelling for me in reading this report as well — there is no talk about a principle-based standardized approach to virtual care system design. So there is no common vision for how this should be.

Avis Favaro

Does that make you frustrated?

Dr. Ewan Affleck

Well, I’m working on it. So, and others are as well. This is not a complicated thing. In fact, it’s actually quite easy to do, but it just needs to be done. And it involves everyone getting together and agreeing on a common approach.
And so the Pan-Canadian Health Data Strategy, we’ve recommended, you know, and this is a strategy that was commissioned by the federal government and came out last year. We recommend something called the Health Data Charter that upholds a clear set of principles around which health information should be designed in order to assure quality of care for Canadians. And that’s basically what I’m talking about.

Avis Favaro

So let me go back to an international example. Can you point to 1 country so that people would understand what they do that we don’t have?

Dr. Ewan Affleck

Yeah. So there’s a variety of countries. Probably Estonia is one.

Avis Favaro

If I’m a patient in Estonia, how does my health data and how does virtual medicine work for me there?

Dr. Ewan Affleck

Basically, it amounts to this fact that your information follows you. I mean, it’s your asset. So they have succeeded in building a network that allows an individual’s information to follow them to the points of care they are receiving so that the best care can be made and errors are mitigated or minimized.

Avis Favaro

So that’s your dream then, having something like that across Canada?

Dr. Ewan Affleck

Yeah, it’s the dream of many people. We know where we want to go. We haven’t quite established how to get there.

Avis Favaro

Is it money? Is it an expensive proposition? Because you have to have not just the networks, you have to make sure people have, even for virtual, the basic virtual care, internet at home. There’s a lot of infrastructure that has to be built in.

Dr. Ewan Affleck

Well, we built a huge amount of fragmented infrastructure already at great cost. The economies of scale by building interoperable systems, if we had done so at the beginning, would have been probably substantive, although I’ve never seen a report or an evaluation of that. And I’m not a health economist.

So it will take certainly some money now, but I think the currency that is most important is recognizing a common problem and building out a cooperative and common approach to that.

Avis Favaro

You’ve used the word fascinating about the whole idea of virtual medicine. Why do you use that word?

Dr. Ewan Affleck

This is not something that one could have done before the digital revolution, before the World Wide Web was evolved. So this is a fascinating opportunity. So there, I get to the word. A fascinating opportunity to improve the care of Canadians all over the country in remote places and urban places and so forth.

So it’s still sitting there for us to engage with meaningfully, but we have to do it based on the common vision in a harmonized way.

Avis Favaro

But based on what you’ve been saying, I kind of feel like we’re still in the dark ages. The digital revolution has come. There are certain things that we’ve adapted to, but largely, other countries have moved far, further ahead more quickly.

Dr. Ewan Affleck

Yeah. And many, many countries around the world, the health care sector is struggling with this. We’re not unique in Canada, although we’re certainly towards the bottom in terms of performing. In terms of integrated digital systems, we struggle.
But I think COVID has been a good thing for our country with respect to our approach to digital health. I’m not saying it’s been good at all, I fully, you know, it’s been a terrible thing, but it’s woken us up to, hopefully, a reimagination of how we’re adopting virtualized services and so forth and this notion that it probably makes a lot of sense to cooperate and collaborate around a common set of standards.

Avis Favaro

Right. Now, from a patient consumer side, I am getting mixed messages. We see the data that people love virtual care. I’m talking about connecting with their doctors with these alternative ways. People love it. They like the option. They do want to have a relationship.

But there’s a couple of issues. We have provinces now that are trying to get doctors back into offices. And you’ve seen some of the fee codes for virtual medicine pulled back. So sometimes I say to myself, well, do they want virtual medicine? They want us to go back the way we were. Are we getting mixed messages? And what do you think when provinces say, yes, virtual care in a pandemic, but meh, afterwards, maybe not that important or we’re not going to fund it?

Dr. Ewan Affleck

Yeah. There’s a real mixed approach across the country from jurisdiction to jurisdiction with this. And there are clinical situations where you absolutely have to see someone in person. And so that’s a big concern.

How do we navigate that so that those receiving virtual care, that it’s appropriate for their clinical situation? These are things we haven’t really figured out. And so this is challenging for provinces. It’s challenging for all of us. We’re sort of inventing this as we go.

That being said, I will suggest that the whole fee-for-service model is probably not terribly well designed for virtualized services. Because, in an ideal situation, if you have a physician or a nurse or a pharmacist or whatever, you don’t want to be creating an environment where you’re rewarding some form of care over another. It would be great if there was some equity in the form of care. So, really, the form of care, whether virtual or in person, should at heart be a clinical decision.

If Avis comes to me and you have problem X, I should be asking myself the question, “what’s the best for your health outcome? That I talk to you on the phone and you can get you in right away? That I see you in person, which may mean a delay? That we do a video or you take an image of something and send it? Like, what is the best way to ensure your health outcome?” And so that really should be a clinical decision.

And the difficulty with forms of remuneration is once differential income comes into play, it can confuse things. Right? And when you begin monetizing illness, it gets challenging for everyone. So ideally, you want to set up an environment where the motive force for deciding what form of communication occurs in your care is based on the patient’s outcome, not on anything else.

Avis Favaro

But what you have is people want virtual care. It’s becoming possibly harder to access. And it’s being offered less.

Dr. Ewan Affleck

Because of the decisions in some jurisdictions, yes, perhaps. I mean, ideally, what we want to do is integrate virtual care into the main publicly funded health system in a way that it is seamless with the in-person care that you have.

There are instances of that, but it’s not always occurring. And we have workforce shortfalls currently. And so those workforce shortfalls mean that there is a lack of access. It’s not an easy time. None of this is easy. And there’s no one to blame.

It is a state of being. My whole message again and again is that we have to sit down and collectively solve for this, looking at the evidence of what is currently occurring.

Avis Favaro

Given that we have so many shortages and physicians are under pressure, nurses are under pressure, nurse practitioners — we don’t have enough. We have 6.5 million Canadians who don’t even have a doctor with whom to do a virtual visit. Should we not be looking at manpower before expanding virtual care?

Dr. Ewan Affleck

Yeah. Ideally, if it’s well done, it will not demand a greater workforce.

Avis Favaro

How urgent is this?

Dr. Ewan Affleck

Virtual care is just health information or health data exchange. That’s all it is. So if we don’t achieve a common, shared and collective vision and harmonize public policy and governance around health data, we will continue to struggle. And so that really is the focus that we need to achieve.

And again, I cannot see how this will not benefit governments, health professionals, patients, First Nations, Inuit, Métis, all of the constituents. So I would say it is one of the core pillars.

So it is important and urgent, and I’m very pleased by the recent bilateral agreements and the commitment by the federal government. And I’ve never seen this much interest on the part of governments and others on reimagining how we use health data in Canada. So I’m very excited right now. And I think the glass is definitively half full.

Avis Favaro

What’s your fear?

Dr. Ewan Affleck

You know, it can be hard to gather people together when a health care system has so many fires to put out. What I fear is that we get distracted by all the fires and not — because this is — what I am suggesting is long-term thinking. This is a slow, gradual process of reinventing our approach to health data in Canada. And this can be achieved, and it will, it will accrue long-term benefit to all of us.

But there are so many fires that it can be hard to keep people’s attention and interest when there’s smoke inhalation and you’re getting burns and so forth. And again, this isn’t a criticism of anyone. It’s just the state of being. But the problem is, and if we don’t address this, there’s just going to be more fires, so.

Avis Favaro

Yeah. I think I’ll leave it there. Thank you so much, Dr. Affleck. I really appreciate it. And I hope virtual care expands.

Dr. Ewan Affleck

Well, thank you, Avis. I appreciate your time.

Avis Favaro

CIHI’s expanded virtual care report now sets the stage for more discussions about how to move forward, how provinces can learn from each other and how Canadians can finally get fully modernized digital health care.

Thank you for joining our discussion. Our executive producer is Jonathan Kuehlein, and a shout-out to Alya Niang, host of our French podcast. And we encourage you to take a look at the full virtual health care report by going to cihi.ca. That’s C-I-H-I dot C-A.
I’m Avis Favaro. Talk to you next time.