Dr. Inderveer Mahal
Family Physician, Fellow - Munk School of Global Affairs & Public Policy

Physician-Patient Consultation is Critical in Developing Sustainable Telemedicine Infrastructure

The COVID-19 pandemic has dramatically shifted how Canadians access healthcare. The era of telemedicine has swiftly and abruptly been ushered in. Telephone visits, video conferencing and a plethora of emerging virtual care apps have become the ‘new normal’ for patients and physicians alike. But unlike the worlds of e-commerce and fintech—which have been connecting consumers and products for well over a decade—the link between the digital world and healthcare is only in its infancy. Ensuring we develop the right kinds of links early on is key to longer-term digital healthcare development.  

Telemedicine involves the delivery of medical care and information through communication technologies. This can be as simple as a telephone call, or extend into the digital world with videoconferencing, email and text messaging. In 2018, only 8% of surveyed Canadians reported having a virtual health visit. Similarly, only 4% of Canadian physicians offered video conferencing. But the pandemic has forced healthcare systems to completely restructure how medical care is delivered with a focus on health technology. And the system has responded. Since the start of the public health crisis, survey results from the Canadian Medical Association reveal that 47% of Canadians have now used telemedicine to communicate with their physician.  

“The pandemic has forced healthcare systems to completely restructure how medical care is delivered with a focus on health technology.”

As a family physician, my own clinical practice has incorporated telemedicine as a tool to maintain access between my patients and our healthcare team. E-fax platforms, video conferencing and phone calls have been central in allowing me to follow up on chronic diseases and manage an ever-increasing number of mental health concerns as the pandemic has evolved. For visits such as a medication refill or follow up of blood work where I have an established relationship with the patient—or the patient with the clinic, and their health records are easily accessible—telemedicine has been an excellent adjunct to my practice. At my chronic pain practice at CHANGEpain, we’ve been able to innovate and leverage virtual health to reduce barriers to accessible pain services and support patients at home. We have now expanded to provide pain psychology classes and movement therapy through online group sessions. For patients with severe mobility restrictions and those in remote areas of British Columbia where access to pain services is limited, telemedicine has helped bring pain services right into their homes. 

But while there is significant upside to telemedicine in some respects, not all visits are appropriate for virtual care. New headaches, enlarged lymph nodes and communicating a new diagnosis of cancer are all examples of patient presentations that require an in-person visit and clinical examination to provide patients thorough and adequate care. On a daily basis, I rely on a colleague who is physically working at our clinic to examine a patient before a clinical decision can be made. For virtual health to thrive in Canada, we must first recognize the limitations of virtual care. New virtual care apps are advertising quick and easy access to a doctor. But accessible care doesn’t always translate to good quality care. Healthcare has the unique position where poor delivery can ultimately lead to higher rates of morbidity and mortality.  It’s critical that we don’t exchange ease and convenience for compromised patient outcomes.  

“For virtual health to thrive in Canada, we must first recognize the limitations of virtual care.”

The development of virtual healthcare tools with thorough physician input and consultation is also imminently required if we want telemedicine to thrive. For too long, administrative decisions and health tech tools are developed without key patient and physician input—the two key stakeholders that engage with these tools. This must include our vulnerable populations. Mental health, addictions and lower socioeconomic status are risk factors for almost all diagnoses. And it’s these populations who run the risk of having higher barriers to virtual healthcare and adverse clinical outcomes. To start, we need to support all Canadians in having access to phone lines and internet—critically missing infrastructure in many northern areas and Indigenous communities. Until then, developing healthcare systems with a ‘digital first’ lens will only create further health disparities and an inadvertent two-tiered system. 

“We need to support all Canadians in having access to phone lines and internet […] Until then, developing healthcare systems with a ‘digital first’ lens will only create further health disparities.”

For physicians, we need digital health tools that allow us to provide the high quality of care we were trained to provide. Electronic medical records (EMR) that allow for video conferencing, e-faxing and direct patient communication to be embedded into the patient’s chart are critical. This is fundamental in ensuring physicians have a streamlined workflow to limit work behind the scenes, allowing them to focus on patient care and reduce the number of patients usually seen in a day. It is well established in the literature that EMRs, when developed without physician input and ongoing optimization based on physician feedback, significantly contribute to physician burnout and reduced job satisfaction.  

Further, research into options and the reliability of physician examination techniques is needed. For telemedicine to truly thrive, we need to be confident we can complete the majority of our virtual health visits at the end of the encounter. Otherwise we risk creating a “second queue” where patients are left waiting for an in-person examination before a management strategy can be made. In this aspect, the $240 million pledge by Justin Trudeau’s government for online health care is critically needed. We must focus on developing tools and apps with key stakeholder input and ongoing consultation. While a plethora of options and variety are a boon in the world of e-commerce, it is far more important that we develop high quality, reliable and accessible healthcare technology that works for all Canadians.   

Finally, adequate reimbursement of virtual care is crucial if we want it to continue in Canada. COVID-19 has pushed governments to respond to the new technology and roll out new virtual care billing codes. But these codes must continue to be available long after the pandemic resolves. They also need to reflect the value of longitudinal, relationship-based care that is the backbone of a strong health-care system. Complex chronic disease planning, counselling, and mental health visits need to have appropriate virtual fee codes—a critical piece still missing in several provinces.  

“Adequate reimbursement of virtual care is crucial if we want it to continue in Canada.”

With no end in sight for this public health crisis, telemedicine continues to be the mainstay of health care. Universal, quality health care now relies on developing thoughtful and accessible telemedicine infrastructure that works for both patients and physicians. There is considerable momentum and financial support for telemedicine right now. Our Canadian governments, emerging health tech companies, patients and healthcare workers are in a unique position to collaborate and innovate to reduce barriers to care and improve health-care accessibility in the long-term.