Digital tools have the potential to improve the patient and provider experience, health outcomes, cost, and equity, but we are just starting to learn how to use them. The variation in virtual care policies and uptake across the country, following the COVID-19 pandemic, created an opportunity to better understand how virtual care can drive equitable, quality, and integrated care. Through three projects, the Canadian Network for Digital Health Evaluation (CNDHE) studied the integration of digital solutions in clinical care, looking at the equitable virtualization of primary care, and asynchronous secure messaging policies and workflows.
Project One: Equitable Virtualization of Primary Care
The first project explored challenges and strategies associated with the equitable virtualization of primary care. The CNDHE conducted semi-structured interviews as part of descriptive case studies across four primary care organizations with experience serving structurally marginalized communities. Findings indicated that activities intended to promote access to virtual care for some may cause unintended barriers and inadvertently exacerbate care inequities for others. Organizations were constrained by funding and policy limitations, leading to partial and incomplete equity-focused virtual care initiatives. Effective strategies to improve the equitable virtualization of primary care include device donation programs, community health worker support programs, and including members of structurally marginalized communities in virtual service delivery planning. Moving forward, a long-term strategy to support digital health equity is needed and includes policies and programs that acknowledges the deep connections between the health system structure, access to care, and digital technology.
Project Two: Policy-Level Facilitators and Barriers to Asynchronous Secure Messaging
The second project compared policy-level facilitators and barriers to the implementation and uptake of asynchronous secure messaging (ASM) across the country. The CNDHE conducted semi-structured interviews with policymakers, vendors, and virtual care experts, and a document analysis of academic literature, provincial reports, and virtual care websites. Results indicated that provincial ASM efforts in primary care differed in scale, duration, remuneration, and levels of integration. ASM was recognized as having clear value for both patients and providers, including convenience, cost savings, and time savings. A long-term vision to embed ASM platforms into existing provincial systems can support ASM integration, as well as appropriate remuneration to incentivize provider uptake.
Project Three: Workflow Integration of Asynchronous Secure Messaging
The third project builds upon the findings of project two and explores ASM at a micro-level; within clinical workflows at Women’s College Hospital. The CNDHE conducted semi-structured interviews with health care providers, administrative staff, and patients across four specialty departments. The team also analyzed aggregate utilization data from the EPIC electronic medical record to explore ASM user characteristics and patterns. Evaluation findings indicated that patients valued the convenience of ASM while administrative staff valued the reduced workload. Physicians found ASM to significantly increase their workload and felt that it was not being used appropriately. Departments that had nurses triage messages had more success integrating ASM into their workflow compared to departments with a high patient-per-physician ratio and those without nursing staff. To better integrate ASM into workflows, guidelines for the appropriate use of ASM should be created and engage all users including health care providers, patients, caregivers, and administrative staff.
The adoption of telemedicine for healthcare service delivery has notably shifted in response to the COVID-19 pandemic – telemedicine is here to stay. In response to this shift in healthcare delivery, the Centre for Digital Health Evaluation (CDHE) has developed this monitoring tool using data from ICES to visually represent the utilization of virtual care across Ontario, and among various subgroups prior to and during the COVID-19 pandemic. We aim to regularly update and monitor this tool.
Total number of ambulatory visits by week, 2019 - 2022
In 2017, the Ontario Ministry of Health undertook the Enhanced Access to Primary Care (EAPC) pilot program, which explored the uptake of virtual care by giving primary care providers a secure platform for voice, video, and asynchronous messaging to conduct eVisits with patients in Ontario. The Centre for Digital Health Evaluation (CDHE) evaluated the use of different modalities for care delivery along with the experience of patients and providers to understand barriers and facilitators to adoption. As part of the evaluation, providers were recruited across five different Ontario regions, with almost 200 providers enrolled in the program. Providers registered over 14,000 patients and conducted over 14,000 visits, with over 6,000 patients completing at least one eVisit over six months. This was the largest evaluation of virtual primary care in Canada at the time. The evaluation found that over 90% of eVisits to primary care providers used asynchronous text and most providers reported having few issues with patients using the platform inappropriately. Overall, patients reported that eVisits saved them time and money, and approximately 99% indicated that they would use this service again.
In 2016, the Ontario Ministry of Health created the Digital Health Drug Repository (DHDR), a database that consolidates patients’ medication history across Ontario. The Centre for Digital Health Evaluation (CDHE) evaluated DHDR’s impact and potential areas for improvement. The evaluation found that DHDR uptake was limited among eligible healthcare providers. Among those who used it, the DHDR was found most valuable during geriatric and surgical consultations, in the emergency department, and when prescribing medications to new patients and those with multiple diagnoses over the age of 65. To increase the adoption of the DHDR more broadly, the evaluation recommended improving the comprehensiveness of data to include private insurance claims and medication instructions, and integrating the DHDR into point of care systems to optimize workflow efficiencies.
This evaluation was funded by Ontario’s Ministry of Health
In August 2018, the regional MyChart patient portal was funded by the Ontario Ministry of Health to go live in South West Ontario (SWO). This portal enabled patient access to their clinical information from multiple health institutions in the region. In 2019, the Centre for Digital Health Evaluation (CDHE) evaluated MyChart to explore experiences with the patient portal, identify challenges with implementation, recommend opportunities for improvement, perception of potential benefit, and key strategies for implementation success. A total of 43 interviews were conducted with a variety of stakeholders including patients, health care providers, and individuals involved in implementing the patient portal. Quantitative usage data was analyzed alongside the qualitative findings. This evaluation found that, while multi-institutional patient portals can enable efficient access to clinical information from multiple health services, successful implementation can be impacted by several factors. Factors that were seen to positively impact implementation included: a blanketed roll-out (instead of implementing across departments in a staggered manner) and strong support of senior leadership and clinical champions. According to the findings from this evaluation, in order to optimize the patient experience, data comprehensiveness should be prioritized, which requires a coordinated approach, aligned policies, and a key base of technology infrastructure that allows for interoperability across participating organizations.
This evaluation was funded by Ontario’s Ministry of Health
In early 2019, the Centre for Digital Health Evaluation (CDHE) evaluated the uptake, impact and use of virtual care across the province of Ontario given changes in care delivery during the COVID-19 pandemic. Virtual care services in Ontario included the use of telephone, video, and asynchronous messaging between patients and providers. The CDHE evaluated the extent and impact of the rapid virtualization of clinical care on patient and clinician experience, and the overall cost and quality of the care provided through the following streams of work:
Stream 1: What is the uptake and impact of virtual care across the province, across regions, and across patient populations?
Stream 2: Does virtual care lead to inequitable access to healthcare services by underserved patient groups across different health settings?
Stream 3: How has virtual care been used in primary care?
Stream 4: How has virtual care been used in hospital settings?
Stream One: Health System
The goals of Stream 1 of the evaluation were to describe the changes in virtual care use that occurred in Ontario during the pandemic and to evaluate the impact of virtual care use on healthcare utilization and patient outcomes. To conduct this evaluation, the CDHE used health administrative databases housed at ICES (Institute for Clinical and Evaluative Sciences) containing population demographics, physician services, and patient healthcare utilization such as hospitalizations, emergency department visits, and lab and diagnostic testing. This evaluation found that the introduction of temporary billing codes for telephone and video in March of 2020 led to rapid uptake of virtual care in the province. Virtual care visits constituted at least 50% of all ambulatory visits in Ontario throughout the first ten months of the pandemic (March 2020 to January 2021). No differences were found in the utilization of virtual visits by neighbourhood income level, however differences were noted for other demographic groups, with higher uptake reported amongst females, urban patients, and older adults age 65 and above. Generally, patients who were high users of virtual care during the pandemic were also high users of the healthcare system before and during the pandemic.
Stream 2: Health Equity
The goal of Stream 2 was to explore the impact of rapid virtualization on equitable access to health care. To conduct this evaluation, the CDHE conducted case studies within five care contexts across the Ontario health system to explore implementation challenges of virtual service delivery and to understand how health equity was considered or neglected during this process. The CDHE also completed a scoping review of the literature to generate insights regarding the most salient barriers to engaging in virtual care among structurally marginalized communities. The findings of the case studies indicated that many organizations did not have extended engagement or training in topics related to health equity to draw upon in their implementation of virtual care and therefore did not always know what solutions to implement to break down barriers to care. In general, it was found that there was a lack of strategies by organizations to ensure access for individuals experiencing auditory, cognitive, or visual impairments, individuals encountering language barriers, and individuals experiencing homelessness. One of the clearest challenges in access to virtual care that arose in the scoping review and case study findings as part of this evaluation was the lack of access to and affordability constraints of the Internet, cellular service, and/or digital devices. Cost-related and infrastructural barriers were most apparent for those living in rural and remote communities, including Indigenous Peoples; and those who are low-income, including older adults on a fixed income and individuals experiencing homelessness. The evaluation team found that meaningful engagement with virtual care is only possible if patients, caregivers, and healthcare providers have the digital literacy to use the technologies effectively. However, many providers and service users may not have appropriate digital health literacy skills to engage in virtual care. It was found that phone calls were widely employed as a strategy to mitigate some of these challenges and served as a crucial tool to ensure equitable access to virtual care overall.
Stream 3: Primary Care
The goal of Stream 3 was to investigate the impact of the rapid virtualization of primary care during the COVID-19 pandemic. To conduct this evaluation, the CDHE included an environmental scan, interviews with patients, providers and administrative stakeholders, and a survey with patients/caregivers and providers. It also leveraged original studies by CDHE partners, including a survey of over 7,000 patients from 14 academic Family Health Teams (FHTs), and electronic medical record data from Community Health Centres (CHCs) across Ontario. This evaluation found that most healthcare visits during the COVID-19 pandemic were conducted by phone due to its convenience, with few visits conducted by video (due to set up and technical issues) or asynchronous messaging (because it was rarely offered and not a billable visit for physicians). Having to triaging patients to in-person or virtual care increased provider workload. The evaluation reported that patient and provider preferences for different modalities varied widely. Moving forward, it was found all participants envisioned a mix of in-person and virtual interactions in the future, ideally determined by patient preference and clinical appropriateness.
Stream 4: Hospital Systems
The goal of Stream 4 was to investigate the impact of the rapid virtualization of healthcare within hospital systems during the COVID-19 pandemic. To conduct this evaluation, the CDHE included four hospital sites: St. Joseph’s Healthcare Hamilton (SJHH), Women’s College Hospital (WCH), St. Michael’s Hospital (SMH), and Trillium Health Partners (THP). Data sources for this evaluation included aggregate clinic-level utilization data, qualitative interviews with patients and providers, and virtual care experience surveys distributed to patients and providers across diverse specialty areas. Evaluation findings indicated that the key benefit of virtual care was the convenience and cost savings produced for patients (e.g., by not having to travel, pay for parking, or take time off work), and reducing patient no-show rates for appointments, along with avoiding COVID-19 transmission in public spaces. The evaluation found that preferences for different virtual modalities vary widely among and between patients and providers and depend on context (e.g., clinical area, access to and comfort with technology, and other work/life responsibilities).
This evaluation was funded by Ontario’s Ministry of Health
Academic publications are in progress, however, if you would like a copy of any of the Ontario Ministry of Health-funded reports, please reach out to firstname.lastname@example.org.