This article originally appeared in the May/June 2020 issue of the Ontario Medical Review magazine.
Tips and tools for physicians
COVID-19 has disrupted every aspect of how Ontarians live and work, including the relationship between physicians and their patients. With physical distancing measures and other health precautions likely to remain in place for much of the year, physicians across the province are using virtual care to support their patients’ health — and their practices.
Virtual care is getting a lot of attention amid the coronavirus crisis, but the concept itself isn’t new. Physicians have long used the telephone to attend to patients remotely for decades, and Ontario Telemedicine Network (OTN), now part of Ontario Health, began providing two-way video conferencing between physicians and patients in the mid-2000s.
“Virtual care is simply care,” says Dr. Darren Larsen, Chief Medical Officer of OntarioMD and a family physician based at Women’s College Hospital in Toronto. “You can offer care in many different ways, and that care should meet the needs of both yourself and your patient. That varies by time and place.”
“Virtual care means a lot of different things to different people,” says Dr. Ilana Halperin, an endocrinologist at Toronto’s Sunnybrook Health Sciences Centre. In addition to video calls, Dr. Halperin notes that phone calls and asynchronous methods such as email and secure messaging are equally valid forms of virtual care — though their use is perhaps limited by the fact that, unlike video calls, physicians weren’t traditionally paid for them. However, changes introduced by the Ontario government in March may signal a shift.
In an effort to stem the spread of the coronavirus, the provincial government agreed to cover some forms of virtual medical care, issuing new temporary billing codes for a variety of services delivered by phone or video.
The Ontario government’s decision to expand virtual care in the context of the COVID-19 outbreak means that any direct-to-patient telephone, telemedicine and video-calling platforms can now be used — not only those that had already been approved for use, such as OTNInvite. Physicians can even employ services not typically used in health care, such as Microsoft’s Teams and Skype, Apple’s FaceTime, Google Hangouts, and Zoom.
Taken together, the government’s recent changes provide a strong incentive for physicians to try to incorporate virtual care into their practice. For some, virtual care is a way to maintain not only their patients’ health, but their practice’s finances, too. That’s where the new Ontario Virtual Care Clinic — developed by the OMA together with OTN, OntarioMD, Novari, and Canada Health Infoway — can play a key role.
The Ontario Virtual Care Clinic initiative began as a way to alleviate pressure on Telehealth Ontario, which found itself overwhelmed with calls about COVID-19 as well as non-coronavirus matters as the crisis took hold, explains Sarah Hutchison, chief executive officer of OntarioMD. Setting up a new virtual clinic to handle non-COVID matters would reduce the burden on Telehealth Ontario while enabling physicians to see patients and keep some income flowing.
“We realized that some physicians have been seeing fewer patients and therefore billings are down,” says Ms. Hutchison. “Some physicians are really feeling the pinch.” More than 900 physicians offered their support for the Virtual Care Clinic during its March development, and nearly 300 were trained and ready to go by the time the clinic “soft launched” on April 3.
| Fee codes |
Description |
Value |
|---|---|---|
| K080 |
Minor assessment of a patient by telephone or video, or advice or information by telephone of video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis. |
$23.75 |
| K081 |
a. Intermediate assessment of a patient by telephone or video, or advice to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes; or |
$36.85 |
| K082 |
Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video per unit (unit means half hour or major part thereof) per unit. |
$67.75 |
| K083 |
Specialist consultation or visit by telephone or video payable in increments of: |
$5.00 |
The Virtual Care Clinic is designed to field patient questions about simple health matters, from coughs, colds, and flu to pain, rashes, women’s health issues, and medication questions. The service is not designed to replace patients’ usual care, and Ontarians are encouraged to contact their family doctor first. Demand for the new service was lower than expected in the immediate aftermath of its April 3 “soft launch”; a subsequent “hard launch” on April 15 promoted the service to patients directly in hopes of bringing more non-COVID calls to the clinic.
COVID-19 may be driving many Ontario physicians to adopt virtual care and video for the first time. Dr. Larsen believes that prior to COVID-19, there was neither a burning platform nor a strong financial incentive to adopt virtual care. “Now the burning platform is here and that’s convinced a lot of doctors to ‘switch on’ very quickly,” he says.
In some ways, the current environment has been a boon for physicians adopting virtual care tools, he notes. With fewer in-person visits requested by patients, they have time to learn and adapt to the new tools. Trying to introduce virtual care into a very busy practice under normal conditions could prove a much more challenging proposition for many physicians and their staff.
Some physicians have already embraced virtual care, of course. Dr. Braedon Hendy, a family physician based in Belle River, Ontario, had been using virtual care with his patients for about a year before the pandemic hit, making the transition during the crisis relatively easy.
“Patients have really appreciated the ease and convenience of virtual care,” he says.
Using video and other forms of virtual care means his older patients don’t need to leave their homes, while patients with full-time jobs, who can’t always afford to take time off work, can continue to see him instead of turning to walk-in clinics or other alternatives.
For Dr. Hendy, virtual care tools also enable him to look after his patients while at the ER or on military duty (he also serves as medical officer with the Canadian Armed Forces).
As an endocrinologist, Dr. Halperin has long found that virtual care is ideally suited to the nature of her practice. She’s been increasing her use of video visits in her clinical practice since mid-2017, and she finds that using video fits very well with her “high-frequency, low-touch” patients.
“I’m a laboratory-based specialty, and so for follow-up appointments, the physical exam doesn’t often add anything. The most important thing is that patients do their labs and we have a conversation about how they’re feeling and how they’re responding to the various medications I’ve prescribed,” she says. In the current environment, her practice is 100 per cent virtual.
When physical distancing hit in March, Dr. Halperin’s office called her patients to confirm that scheduled appointments would be kept — but take place by video or phone. She didn’t want patients to defer appointments because it could create a capacity issue in the future and interfere with patient flow, she explains.
“We’re already starting to see people deferring non-COVID-related care. We’re going to see the fallout from that with increased hospitalizations. When people finally come to the hospital they’re quite unwell, because they didn’t come as soon as they should have,” she says. Virtual care provides a way to keep in touch with and triage patients before it gets to that point.
Virtual care may enable physicians to use the latest video technologies to treat their patients, but it also enables them to bring back something very traditional: the house call.
Many doctors have reduced their house call volume dramatically over the last 10 or 15 years, notes Dr. Larsen. That includes him: prior to joining Women’s College Hospital, he had a fairly active house call practice involving senior patients and palliative care. Now he’s in a teaching practice, most patients come to him.
“Something is lost when you’re not seeing a patient in their house,” he says, recalling how he learned surprising details about his patients’ lives during visits to their homes. For him, virtual care provides a new way to gain similar patient insights. “You get a view in to a person’s natural state. You get to see what their environment is like.”
Ensuring virtual care visits are effective requires some preparation. The first step is obtaining patient consent. Information vetted by the OMA and OntarioMD legal teams and the Canadian Medical Protective Association has been created to make this easier.
Ensuring patients have the capability to participate in video-based virtual care is also important. Physicians shouldn’t assume every patient can, should, or wants to use video. Giving them an option, whether phone or asynchronous messaging, for example, is important. Patients should also be encouraged to gather their medications and prepare their questions in advance of the call as well.
Physicians and patients alike should also be ready with a “plan B” in case of unstable Internet connections or other technology issues. Usually, that backup plan will involve the phone — phones rarely fail, after all.
As long as COVID-19 continues to threaten our health and well-being, virtual care is likely to play an increasingly important role in enabling Ontario physicians to monitor and treat their patients. But what about after the pandemic ebbs?
Dr. Hendy believes physicians using virtual care tools during the COVID-19 crisis will quickly come to appreciate their value. They’ll continue to leverage them and be inclined to adopt new technologies more quickly in years to come. “Physicians will realize that virtual care tools benefit not only the patient, but themselves, their work-life balance, and their flexibility,” he says.
Dr. Larsen agrees. “When we get back to some semblance of normal over a few years, this will just be part of our care,” he says. “The cat’s out of the bag. It’s not going back in.”
Robb Hare is a Toronto-based writer.