Virtual Care in Canada — Dr. Onil Bhattacharyya

Alya Niang

Canadians were introduced to virtual medicine when COVID-19 spurred most of the country to use their phones and computers for health care.

According to data from the Canadian Institute for Health Information (CIHI), the number of patients that benefited from virtual services has quadrupled compared with the pre-pandemic period.

This is no surprise to physicians like Dr. Onil Bhattacharyya.

Dr. Bhattacharyya is the director of the Institute for Health System Solutions and Virtual Care, as well as a family doctor, an associate professor and the Frigon Blau Chair in Family Medicine Research at Women’s College Hospital.

Dr. Onil Bhattacharyya

It’s a significant change.

Really, when you think about how services were organized in the past, access was limited because you had to call the office, make an appointment, get yourself there and all that, which meant that many people didn’t go to the doctor even if they needed care.

Alya Niang

Hello and welcome to the Canadian Health Information Podcast (CHIP). I’m your host, Alya Niang.

Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of CIHI. However, this is a free and open discussion, and today’s episode is about the relationship between CIHI and the expansion of virtual care.

Canadians wanted it, and they finally got it. Now, what’s the next step?

Hello, Dr. Onil. Welcome to the podcast.

Dr. Onil Bhattacharyya

Hello and thanks for having me.

Alya Niang

Dr. Onil, virtual care has existed for a number of years, but the pandemic played a key role in its adoption in the last few years.

Why was this the case when Canadians have been interested in it for such a long time?

Dr. Onil Bhattacharyya

The use of virtual services hardly changed in nearly a decade. When you look closely, it barely changed at all. Then in March 2020 there was a huge increase. Up to 80% of outpatient interactions took place through virtual care.

Why was that? The pandemic required us to physically distance, so people couldn’t and didn’t want to receive care in person if they could help it.

But more importantly, the way of being paid for these services was different.

In the past, in Ontario, for example, there were price lists for virtual care, but only through the Ontario Telemedicine Network, which were fairly limited.

And then they changed their minds and said it was okay to provide it over the phone, then just by video. But when they said video, phone, any platform was acceptable and we were paid the same as for in-person services — that, in addition to social distancing, led to a massive increase.

Alya Niang

Can you explain to us what virtual medical care is and how it’s changing how health care is delivered?

Dr. Onil Bhattacharyya

The central idea with virtual care is that there’s a physical separation, but possibly a separation in terms of time as well.

Care is provided over the phone, by video or by text, where we communicate in many different ways by talking, through video or by texting.

But, essentially, through these services, people can provide all sorts of information: videos, photos of wounds, information about blood pressure readings, etc.

What’s changed for me is the idea of distinguishing an appointment, which is a simultaneous, in-person event, from a situation in which all types of exchanges can happen at the same time, but not necessarily simultaneously, such as by text or email.

Alya Niang

Is this virtual care — the way we’ve been providing it since the pandemic — working?

Dr. Onil Bhattacharyya

Is it working? Well, it allowed for social distancing. It certainly enabled us to maintain sufficient access during a period of social distancing. However, the goal was to minimize COVID transmission, not to improve the quality of care.

Now, 3 years later, we’re starting to think more about how it can help support and improve care.

But, certainly during the first 2 years, we weren’t thinking about that.

So I’d say that it helped in some ways, but we haven’t seen its full potential yet.

Alya Niang

Right. How can virtual care improve access to care, particularly in rural or underserved areas?

Dr. Onil Bhattacharyya

The most obvious way is by providing access to a doctor or nurse without having to go anywhere. It’s a significant change.

Really, when you think about how services were organized in the past, access was limited. You had to call the office, make an appointment, get yourself there and all that. That meant that many people didn’t go to the doctor even if they needed care, because they worked full time, lived far away, had mobility issues or had small children. There were all sorts of reasons why services weren’t accessible.

With virtual care, all types of people can get care. I have patients, social workers, who call me from the hospital between 2 clinics. There are people who work in factories, who find a quiet spot for an appointment, which they couldn’t do otherwise.

So I think that’s maybe the most significant aspect.

Alya Niang

But I imagine there are limits. Can you explain to me the types of medical services that can be effectively delivered through virtual care?

Dr. Onil Bhattacharyya

If we look at virtual care like a stage in an episode of care or in care in general, we can establish an agenda.

I’m a family doctor. When I see patients, most people don’t come to me for 1 thing. They come for 5 things. I could determine the 5 problems they have and decide which ones to resolve today over the phone, and see them next week after getting a blood sample and other things. I can see them in person to resolve the other 3 issues.

It’s clear that when we look at virtual care as a stage, we can resolve all sorts of things.

There are plenty of problems, such as mental health issues, that are handled well remotely by video or on the phone.

And then there are other services, health management, high blood pressure.

Before, a patient would come see me and I’d take their blood pressure and say, “That seems a little high. I’m going to increase your prescription.” Now, by phone or video, I get sent 50 blood pressure readings. I look at them and say, “80% of them are good. Only 20% of them are high. I think it’s okay.” Or, “80% of the blood pressure readings are high. We need to increase your medication.”

It’s much more reliable. It’s even better than what we were doing before.

Alya Niang

But you’re a family doctor and some of your colleagues have said that virtual care has improved access but to the detriment of quality. Do you agree?

Dr. Onil Bhattacharyya

I’d say that what we were doing during the pandemic was absolutely the right thing for that time.

When 80% of our care was provided virtually, if someone had a backache, we said, “Okay, bend over. Does it hurt? Lift your foot like this.” That wasn’t good. It wasn’t great care, but we were extremely restricted in terms of physical contact.

Since we’re at 37% virtual care now, I think the quality could be much better.

We obviously have to choose, but during the first, second and third waves of the pandemic, the goal wasn’t about improving care. The quality of care was poorer because our goal was to minimize COVID transmission, not to improve care. That was during the first, second and third waves.

Is it worse now? I’ve done a number of studies and literature reviews looking for evidence that the quality was worse and that harm was done. I haven’t found any.

That doesn’t mean that it didn’t happen, but we don’t have any systematic evidence that the care was worse.

I imagine that it likely was, under certain circumstances. But if you fast-forward to 2023, we’re still in a period where we have the potential to further improve care.

Especially when you keep in mind that health care includes all sorts of things. Information triage for a patient is an example. Do they need to be seen in 2 hours, 2 days, 2 weeks or 2 months?

This is done virtually and often not particularly well. That kind of urgent triage is the first aspect.

The second aspect is diagnosis and treatment, which we touched on briefly. But once we have a treatment for the diagnosis, we’re limited in what we can do with photos over the phone and by video. But we can still do quite a bit.

But the other aspect, the educational part, works very well virtually.

We can send information, look at links and record the appointment so the patient can remember it better.

There are all kinds of things we couldn’t do before. In the past, I would explain things during an appointment. Since the patient would feel stressed, they’d only remember half of it. Then they’d go home and that would be it.

Now, especially with elderly patients, I provide a summary of the appointment: “Here’s your diagnosis. Here are the next 4 steps in your treatment. Do this, then click on this link.”

It’s definitely better in terms of education than what I was doing before. And that’s just because we’re more comfortable with the tools now.

Alya Niang

Personally, I feel that virtual care is effective in some cases. I usually prefer in-person care, but I’ve tested it out with my child’s pediatrician and it works great.

I save time. It takes 1 phone call and I get the information I need. Sometimes I send a picture ahead of time, for example, if it’s an injury. And afterwards, the consultation goes very well.

Dr. Onil Bhattacharyya

Yes, it just needs to be used appropriately. If it’s around 30% of care, it probably... The question is whether it’s the right 30%. The appointments are virtual, so it remains to be seen.

But, if we’re still talking about the positives, during the pandemic I had patients who had moles or lesions and were worried they were melanomas. I now have high-quality photos, dated 6 months apart, over 3 years. I can put them side by side and compare the size and appearance of each image. I can send all this information to a dermatologist, and they can say, “No, it looks fine. It appears benign.” Or, “Oh, that’s a little suspicious, I see this change here.”

In the past, we looked at them and, if we were being thorough, we measured them. But we didn’t take pictures of every lesion, then put them side by side to see what changed over 3 years. Now that’s become routine.

Alya Niang

Interesting. You mentioned earlier having carried out some studies. Are there any that show that virtual care is effective and cost-efficient?

Dr. Onil Bhattacharyya

With regard to effectiveness, we’re seeing advantages in terms of time and logistics for patients. It’s fairly unanimous that it’s easier for several types of patients.

There are many studies that show that for counselling, for example, it’s equivalent.

Certain types of infections, such as urinary tract infections, are comparable.

There are some things, like ear infections, that it’s not as good for, which isn’t surprising. Although some people now use an otoscope with a camera, and then they can send the photo. We may see some benefits, but to say it’s an equivalent for many things... In terms of prescribing antibiotics, it’s better for some conditions than others.

So that’s what’s the literature shows. It isn’t really systematic.

What’s interesting to me is that, in general, in-person care is compared with virtual care. Are they really comparable? We aren’t questioning whether it’s good overall. Because there are plenty of in-person services that aren’t necessary, but we don’t question them.

You know, when I started my training — I started practising 20 years ago — it was the norm for patients to come in and get their prescriptions refilled, which makes no sense. It’s a waste of everyone’s time.

Alya Niang

Yes, a real waste of time.

Dr. Onil Bhattacharyya

So that wasn’t quality care, but it was the norm. Whereas now, we’d never do that.

Alya Niang

Dr. Onil, how does virtual care compare with traditional in-person care in terms of outcomes and patient satisfaction?

Dr. Onil Bhattacharyya

In general, patients like the experience. They find it more convenient. It’s easier to fit into their schedule. However, there are certain subtypes of patients who prefer to be seen in person.

But when you look at surveys, such as those by Infoway, you can see that patients want to be able to refill their prescriptions. Nobody wants to do that in person.

As for annual physical exams, most people want to have them in person, so it varies by condition.

And I think that’s the key. It’s just about making sure that we’re using it to treat the right issues with the right person in the right circumstances.

And I think what’s sort of new is the idea, which began during the pandemic really, of doctors determining the means.

We didn’t systematically ask, “Would you like to have the appointment in person, over the phone, by video or by text?” We didn’t ask. We said, “You have a phone appointment on such and such a day. The doctor will call you on such and such a day at such and such a time.”

What we’re trying to do now is ask each person and document their preference. And it’s going to be quality care. But we’re at the beginning of that process.

Alya Niang

Now the patient has a choice.

Dr. Onil Bhattacharyya

That’s the idea. Appointments by text aren’t covered in most provinces. So I don’t think that method is offered in a standard way, two-way texting. One-way texting from the doctor to the patient is extremely efficient.

One example is telling you that you’re overdue for cervical cancer screening and asking you to make an appointment. One clinic told me they sent out 1,300 messages like that in 2 minutes, and 13% of the people responded.

Alya Niang

That’s great.

Dr. Onil Bhattacharyya

It’s so much more efficient than calling or even sending letters.

Alya Niang

Indeed, very efficient.

Dr. Onil Bhattacharyya

So that’s a clear example.

Another one would be if you have hypothyroidism. Say we took a blood test. The results come back. They show that your medication or thyroid function has decreased. So we change your medication.

We send the information by fax and ask you to get a blood test in 4 weeks. We mention that the requisition is attached below. That’s a 2-minute interaction. It’s very efficient and all the information is provided.

So there are things like that that are clearly more efficient. But you have to develop the tools, etc., for it to reach its maximum potential.

It hasn’t been as efficient in triage. For example, my schedule shows that a patient needs a phone appointment. I call them. They say they have back pain and have such and such issues.

I say, “Okay, you’ll need come in tomorrow at such and such a time in person.” So then, we have 2 interactions when we could have had 1. But if the appointment is brief, it’s not the end of the world.

Alya Niang

According to CIHI data, from January 2021 to March 2022, about one-third of patient-reported appointments took place virtually. And 38% of family doctor consultations and 27% of specialist consultations were still held virtually. In addition, during that period, virtual care remained more common than before the pandemic, although the proportion of virtual appointments decreased compared with 2020.

Dr. Onil, what are we doing for Canadians who don’t have family doctors or even nurse practitioners?

Dr. Onil Bhattacharyya

That’s a very good question, and there are many. The latest data I’ve seen shows that 6.5 million people don’t have a family doctor. That’s according to an iCARE study led by Tara Kiran, a colleague of mine.

Not only that, but there are 7 million patients whose family doctor is 65 or older. And we receive 500,000 new immigrants per year. So, as you can imagine, in 5 years, the problem will only be worse than it is now.

Alya Niang

Clearly.

Dr. Onil Bhattacharyya

So, what are we doing for these people? The idea right now is to have intermediate care.

There are several regions that are testing different approaches, but if we had a virtual or phone approach first, with physicians who may be in the same province or elsewhere... As you likely know, in Canada, in the Maritimes, there’s an acute shortage of family doctors, so these services could be provided by physicians in other provinces. Because we don’t have enough.

Then there’s purely virtual care. One option, and this is where I think we’re heading, is for people to have access to nurses, paramedics, EMTs or others to supplement in-person services. So people could receive virtual care from a doctor or nurse practitioner with on-site staff who could see them.

Then, the idea is to triage patients. We’ll figure out who wants a family doctor, who has an urgent need, and we’ll start creating an attachment program for the people who need a doctor most.

But it’s a work in progress.

Alya Niang

Dr. Onil, it seems like we’ve gotten a taste of the convenience of virtual care, but the numbers are currently down.

Some provinces are reducing billing rates to encourage physicians to practise more face-to-face medicine.

As well, 12 private companies are billing patients for virtual appointments with a family doctor. Ottawa is currently looking to clamp down on these payments by clawing back health transfer payments from the provinces that allow them.

Are we getting mixed messages?

Dr. Onil Bhattacharyya

Absolutely. I think most people thought we went too far during the pandemic and we’re trying to restore some balance.

Of course, when we talk about private companies, there are services that are only virtual, that are more like... the word escapes me, but in any case, they’re walk-in services. They’re occasional services without continuity of care. Some governments consider these services to be lower quality, so they pay less for them.

One of the goals is obviously to try to limit the growth of these services and facilitate continuity of care.

So that’s one message. And the other one, I think, is they basically want to try to restore some balance. The problem is, to go back to the idea of unattached patients, that if we limit purely virtual services and we want to promote continuity of care, there will be less compensation for providing care to people who don’t have family doctors. So that group could suffer.

But with a limited pool of physicians, somewhere along the line, we’d like to see more physicians providing continuous, comprehensive care and fewer providing occasional, purely virtual care.

But, in any case, we’re in a transition period. All that to say that, yes, there are mixed messages. We don’t know exactly where we’re going, but in the next 2 years, I think there will be more clarity.

Alya Niang

Dr. Onil, one of the points made in the CIHI report is that virtual care in Canada seems to be lagging behind other countries in terms of sharing patient health information between health care providers.

How far behind are we and what do these other countries have that we don’t? What do they have more of than we do?

Dr. Onil Bhattacharyya

Yes, it depends on the country, but one issue is interoperability standards, meaning that all computer systems should be communicating according to a shared standard, which we don’t have in Canada. That’s 1 issue. Even in the U.S., they’ve made a lot of progress in this area, but we haven’t. It’s underway, but that’s 1 issue.

The other issue is developing systems for sharing information that are managed by the patient. Again in the U.S., there’s a whole system for sharing health information that’s managed by the patient.

The idea is that if the information belongs to the patient and the patient wants organization A to share the information with organizations B, C and D, they have a duty to do so. We don’t have that here.

We don’t have the ability and the duty to share information.

So, those would be the biggest differences. The lack of standards and the lack of a legal duty to do it.

Alya Niang

I see. So, are we on the right track?

Dr. Onil Bhattacharyya

I hope so. You know, it’s funny because a lot of the companies that manage information at the hospital level, for example, are American companies that already have a much better standard than the Canadian standard, which we could just apply.

However, the organizations that handle information and computerized records for primary health care are mostly Canadian. So, we should put pressure on those organizations. The government has never done this.

Very little pressure has been put on these companies, and they’re left to their own devices.

There’s still a timidness in industrial relations that’s particular to Canada, whereas other countries have been much more aggressive. We need to protect patient and public care from these companies.

Alya Niang

Right. Dr. Onil, how urgent is it for health care systems to ensure that people living in remote and rural areas have equal access to virtual care? What are the remaining technology gaps?

Dr. Onil Bhattacharyya

The gaps are mostly in terms of infrastructure for bandwidth. Of course, in some regions, we have satellites, but it’s still fairly limited.

It’s about ensuring we have the minimum. For phones, it’s fairly good. Most regions have phone access, but the pandemic has shown that phones are an important and useful tool for care. So, we’ve already made progress there.

The next step would be to improve bandwidth in rural areas.

It’s interesting. I was talking to someone from Saskatchewan, and internet service is provided by SaskTel, which sees it as a public good. Whereas in many other provinces, it’s managed by companies that see it as service that you sell to people who can pay for it, so they invest in infrastructure where it’s profitable.

But really, bandwidth and internet access are like electricity. And they should be seen as essential public goods, like drinking water.

So that’s a transition we haven’t seen yet in most regions.

Alya Niang

Thank you.

Dr. Onil, as part of the latest health agreement between Ottawa and the provinces, a new pan-Canadian health data strategy has been announced. How do you think this will impact virtual care?

Dr. Onil Bhattacharyya

It includes all sorts of principles with regard to the patient, who owns information and how information is shared. I see this as an important tool in supporting virtual care. So, it’s a good step. The fact that it’s included in the agreement, I think, is very important. And I think it’s an important step and really a great initiative.

Alya Niang

How important is the pan-Canadian adoption of electronic medical records to the future growth and success of virtual care?

Dr. Onil Bhattacharyya

For more advanced computerized medical records, all of these features are included. Text messages, videos, audio, all of this is already built into the computerized record, which makes it very easy to have the interactions we’ve talked about.

And one thing is particularly interesting... because, ideally, a virtual interaction is carried out in multiple ways. I can give you an example. During the pandemic, I remember, there was a child. I was talking to the mother on the phone, and I needed to see the child. We went on video and I saw a wound, but the resolution wasn’t good. I asked her to send me a picture of the wound, so she sent me a high-resolution photo.

And then I sent the diagnosis and everything by text message. “You have such and such. Take such and such medication, and follow up in such and such a time.” So, everything was integrated. We used video, texting, photos and audio, without opening anything. And it’s all in my file.

Alya Niang

That’s great.

Dr. Onil Bhattacharyya

It really is wonderful. These kinds of methods will only facilitate services.

The next step that we don’t have in Canada, but that we see a lot in the U.S., is a file that’s fully accessible to the patient. The patient can read and even write in their medical file.

Alya Niang

That’s terrific. Is this something that Canada will adopt?

Dr. Onil Bhattacharyya

I think so. There are good points and... You know, some aspects are more difficult. It will take an adjustment.

But the advantage is that, to monitor a situation, for example, patients can include information, their blood pressure, their blood sugar, etc. All sorts of things can be included directly in the file.

So it helps in gathering all the information. It has a lot of potential.

Historically, computerized medical records have been good for billing and have been kind of like an electronic version of our paper records.

What we want in the future is something more like a dashboard, which supports decision-making and facilitates communication. And that’s where we’re headed.

Alya Niang

That’s wonderful.

There has been a lot of talk about getting more data from the provinces about changes. What’s the impact of having data that can be compared across Canada in terms of advancing virtual care?

Dr. Onil Bhattacharyya

There are many impacts. For one, it’s been said that we don’t know what the appropriate proportion is. It’s also unclear how to bill in a way that improves the quality of care and the appropriate use of virtual care. We don’t have the answer.

But we have 13 jurisdictions that have 13 billing systems and we can assess virtual care over the last 6 months. If there’s a change in billing in the next 6 months, what do we see changing? We can compare that 13 times.

Within 2 years, we’ll have a good idea of the best way to bill for virtual care.

We can take advantage of the natural variations across all provinces and territories to learn how to provide this care.

Alya Niang

Dr. Onil, how do you see the future of virtual care? How will it evolve beyond phone and video calls?

Dr. Onil Bhattacharyya

In my view, virtual care supports all the core functions of health care.

When it comes to triaging, when you think of a physician who has, say, 1,200 patients with a whole series of problems, who needs what and when? We don’t have a good solution.

But we could collect and analyze the data, try to understand who needs what at a given time and how to solve their problems, through information triage, the diagnosis — which we touched on — and the treatment.

What’s missing right now with treatment, for example, is that it often takes several treatments or tests to arrive at a diagnosis before you find the right one. Documenting the sequence of care is easier through virtual care because exchanges can be documented easily and information between appointments can be included. So that’s something that I think will help us in diagnosis and treatment.

I already mentioned the educational aspect.

Monitoring a population, high-risk patients as well as average patients, is almost never done but could be done routinely in the future.

And the last thing would be coordinating care between primary health care, home care and hospital care. Facilitating the integration of care, which is still more efficient through virtual care.

We’re just starting to develop all these functions that make up medical care, most of which we’ve provided inadequately until now.

The digital tools that help us deliver virtual care will allow us to improve the core functions of primary health care, which have been inadequate, in my opinion. They will help us do a much better job in the future.

However, this will require major organizational changes.

Alya Niang

Dr. Onil, do you have any concerns?

Dr. Onil Bhattacharyya

I’d say that my main concern is that so far, virtual care has been used to minimize COVID transmission, as we discussed. Now it’s being used in part because patients want it, and it has persisted.

But I’m concerned that we’re moving toward service similar to the transition at Air Canada, from in-person to phone service. All of a sudden, we’re using it to save money and then limiting the public’s access to health service. That would be a concern.

But I’ve never heard anyone say that we’re going to switch to virtual care to limit access and reduce costs. Because the level of care could deteriorate through virtual care. If that was the goal, it has a lot of potential for that. To get to a point where we start with texting and then decide if it’s worth a phone call. It could be used to limit care.

But, for now, I think the idea is more about adding options.

Alya Niang

In fact, the idea isn’t to provide less care, but to add options for patients and make things easier for them.

Dr. Onil Bhattacharyya

Exactly.

Alya Niang

Thank you very much for your time, Dr. Onil.

It was a pleasure to discuss such an interesting and important topic with you.

Thank you again.

Dr. Onil Bhattacharyya

Thank you. I enjoyed the conversation.

Alya Niang

CIHI’s report on expanded virtual care has set the stage for a number of discussions on topics such as

• How do we move forward?
• How can the provinces learn from each other?
• And how can virtual and in-person care be integrated in even better and more sustainable ways to meet the needs of Canadians and caregivers across the country?

Thank you for joining our discussion.

Our executive producer is Jonathan Kuehlein, and special thanks to Aisha Minott and Avis Favaro, the host of the CIHI podcast in English.

For more information on the Canadian Institute for Health Information, please visit www.cihi.ca.

Don’t forget to subscribe to the Health Information Podcast and listen to it on the platform of your choice.

This is Alya Niang. See you next time!