Striking balance with virtual health care

With virtual care now a permanent official component of Ontario’s health-care system, physicians continue to experiment with how best to serve patients under a hybrid model. In this podcast, Dr. Hemant Shah, Toronto hepatologist and vice-chair of the OMA’s Negotiations Task Force, and Dr. Stephen Cooper, a family practitioner on Manitoulin Island, discuss the rise of virtual care out of necessity during the COVID-19 pandemic, and how, by weighing the benefits and challenges, a balance between in-person and virtual care must be struck to ensure quality health care for all Ontarians.

Transcript

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Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

Ontario has just approved virtual care as a permanent official component of its healthcare system. In this episode, physicians talk about the benefits and possible drawbacks of offering medical care virtually.
 
Dr. Hemant Shah is a Toronto hepatologist and vice chair of the OMA's Negotiations Task Force.

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Dr. Hemant Shah: From the perspective of doctors and patients, I think virtual care has been a tremendous asset through the pandemic. One of our greatest concerns for our patients was how we would be able to continue to provide them access to health care if and when the pandemic came to Canada. And because virtual care was enabled so quickly, we were able to very quickly transition where it was safe to do so and where we could provide high quality care to a virtual care setting for our patients. And I think without it, we would have been in big trouble in terms of really making sure that we looked after Ontarians well. It came together out of necessity, but it allowed us to keep looking after people like we always do.

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Dr. Shah: From my perspective as a practitioner, it is critical that we're able to continue offering virtual care in the long term. We always offered virtual care, even before the pandemic, but there wasn't a lot of it happening, and the transition from a little bit of virtual care to a lot of virtual care probably would have taken years, if not decades, to have achieved. But the pandemic accelerated everything. And I think what it showed us was that we can safely, effectively deliver some kinds of care without an in-person, physical encounter with a patient.

But on the other hand, some types of care do require an in-person, physical encounter. And I think what is really important, and what the pandemic and emerging from the pandemic will have us do, is really understand which types of patient en counters can be delivered virtually and which have to be delivered in person, and it is going to be driven by what's most appropriate for an individual patient.

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Dr. Shah: When virtual care is appropriate and when it isn't, I think, is area that is evolving, and probably something that's going to require some continuing professional development for physicians and healthcare workers broadly.

We usually can anticipate what the needs of the patient are going to be at a given encounter based on information we have before starting. And so, it's really a matter of being proactive and planning your day and your clinics, looking at your lists ahead of time, asking yourself, "What is the person presenting for, what is their health care need, and can I address that need virtually or in person?" 

I think that, as time goes on, we're going to see regulatory bodies and provincial and national medical associations step into this field with frameworks that help guide our decision making on when a visit is appropriate to be delivered virtually and when it isn't. But in the absence of that, it's going to come down to the professional judgment of individual physicians who are set out to deliver the best possible care to their patient and have a duty to do that. 

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Dr. Shah: Patients have an innate desire, for the most part, to be seen virtually, because it is often felt to be more convenient — they can have a quick visit during a break at work rather than stepping out of the office and heading over to the physician's office.

I think about my own practice. I know that there are some things I can do really well virtually; I can look after a person with a stable chronic disease that's followed closely with labs and imaging on a virtual basis, whereas a patient who has a changing complex chronic disease, especially one that is more severe, I can't adequately look after that person virtually because there is so much that I can learn from that physical encounter, seeing an individual, examining an individual.

I have a patient who has a long-standing autoimmune liver disease, and I've been seeing this patient for a number of years. They've been quite stable, but the nature of autoimmune disease of the liver is that it can change, and it can change for any number of factors which aren't entirely predictable or avoidable.

And so, this particular patient was telling me through the first few months of the pandemic that they had been gaining weight. At first I thought, well it's just, you know, the “pandemic 15” that so many people were experiencing. But kind of as time went on, the weight gain continued. And the patient was not concerned about it, but I began becoming concerned because one of the complications of liver disease is that you can collect excess fluid in your body, and it's a sign that the liver is not functioning properly.

And I was doing video calls with this patient. And, on a video call I was not able to adequately examine them. And the nature of my practice is that I do follow people from all over the province, and this person lived about three hours away. And so, after two or three successive visits, where I was trying to explain the value and importance of coming in to see me, the patient did agree. And it turned out that this patient was developing a condition called ascites, which is a collection of fluid in the abdominal cavity, which is a sign of liver failure. And it did turn out that they had an infection as well. And so, while they felt relatively well, they actually were brewing something that if it had been left unattended, could have turned into something serious.

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Dr. Shah: I think that there is a potential for patient and healthcare provider expectations to be mismatched when it comes to virtual care. However, I think that's not uncommon when you deliver health care, whether it's an expectation mismatch around modality of care, type of care, required frequency of care, the medication that I might prescribe. And what it's going to come down to is honest, open communication with patients.

I think the pandemic effect of 50, 60, 70, 80 percent of visits being virtual at some moments in time, that probably is too much and is driven by an external dramatic environmental effect that once, in the long term, hopefully  the pandemic being behind us, we're going to settle into a mix. But that mix will probably slightly favour in-person visits.

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Balogiannis: Dr. Stephen Cooper is a family practitioner on Manitoulin Island.

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Dr. Steven Cooper: Virtual care has worked very well both for doctors and the patients. From the patient's perspective, they find it convenient and timely. Physicians actually find the same thing — they find it convenient, they can provide a built-in flexibility of where they provide the clinics, and the flexibility of adding some smart systems into the appointments with some diagnostic assisting.

Both physicians, patients, the ministry, and other healthcare administrators had recognized that virtual care was going to be a part of the future of the healthcare system for a variety of uses. Patient experience being probably the most important, but also availability, access, and easier distribution of clinical time. By that I mean that you can get physicians outside of geographical area contributing to patient care using virtual care.

We knew that before the pandemic, it was just the pandemic sort of sped that along.

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Dr. Cooper: I’m a primary care provider in three different communities. Now, if a patient needs to access me on one of the days that I'm not in those communities, I can do it with virtual care, so that makes me more available to them. Now, I actually had COVID for a short while and I was able to continue on doing clinical work, not in person. But it also means that I can do some care when I'm doing education or courses or administrative work outside my community area.

Virtual’s gotten a bigger and bigger component as patients become more accustomed to it, and are preferring it as a choice of communicating and doing their encounters. We haven't really integrated much of the video work into our practice, and that's because of patient preference — they prefer the telephone over the video, I think for ease. And I have to say, having participated in a number of conferences, and having worked with my mother and my mother-in-law on setting up Zooms meetings, the phone is so much easier.

But I think where virtual is set to come into really helping patients and providers provide an enhanced experience and advanced care, it's where we can start adding some smart systems. You can share the screen, you can look at results together, and you can look at scenarios together, truly make an informed decision about treatment plans. Those are not available on phone.

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Dr. Cooper: So, what we've learned from the pandemic is that virtual care does not solve all the problems. I think from a patient perspective, a realization that part of what makes visiting with a clinician an important part is being there in person so they can express themselves in person.

So, I think from both the providers and the patients’ perspective, there's a recognition through the COVID times that it's important to have a component of the relationship being in person. Understanding a patient, it's not just about understanding a patient, it's understanding the community they live in, and living in that community as well. 

The worry with the virtual care is that patients, clinicians, and ministry may start thinking that the virtual care is adequate. And by not living in the community, not understanding the community you're working in and providing health care, you're missing an important part of that healthcare system, and I believe that for primary care. 

Some specialty care can be done very effectively remotely, and some intermittent parts of primary care, I think, can be done well remotely. But for many specialty —and almost all primary — care, there needs to be a component of the clinician being in the community to provide that care to their patients.

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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.

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