Virtual Health

Virtual health has an important role in rural and remote communities where access to health-care services can be challenging. 

There are many different ways care can be delivered virtually.

Virtual health is convenient, reduces travel, and allows patients to see specialists close to home. Virtual health is an important tool to improve rural health-care access and the health of rural communities. 

 Virtual health describes the use of information and communication technologies to provide health care to patients when the clinician and patient are not at the same location. – Totten et al, 2016

Making virtual health happen in rural areas is not easy. Virtual health requires reliable, high-speed internet. Rural residents also need to learn about the benefits of virtual health and how to use virtual health tools. Other challenges for virtual health emerge from the way health professionals are regulated and paid.  

Despite these challenges, virtual health will continue to grow as technology advances and more people become more comfortable with virtual health. 

Virtual health is transforming the health-care industry. The private sector, where individuals pay a fee for health care services, is already offering virtual health services directly to patients and employers. The use of virtual health has increased rapidly in countries like the UK and the US because of technological advancements and clear evidence that virtual health is effective. For example, Kaiser Permanente, a highly integrated health-care system in the US, delivered 59% of their care virtually in 2017. This has increased to 90% in the COVID-19 pandemic.

Canada is lagging behind other countries in the use of virtual health. Some of the barriers Canada is dealing with include:

• Data systems to exchange patient information don’t  seamlessly connect between different health-care facilities, health providers and patients  
• Quality care safeguards to make sure virtual health is as safe and effective as face-to-face care  
• Current health providers are not trained to use virtual health efficiently and safely  
• Medical and health sciences students are also not trained to use virtual health tools 
• The general population/patients are not always aware of virtual health options 
• Health-care provider regulation & payment  

With all the barriers to address, the adoption of virtual health in Canada is slow.  

Many countries have developed national strategies for virtual health. In Canada, the Virtual Health Care Task Force has created such a strategy with the goal to promote virtual health and overcome the barriers.  

The COVID-19 pandemic has shown the importance of virtual health to keep patients and health providers safe and offer seamless care during physical distancing orders. This has pushed the adoption of virtual health Canada-wide, and many health clinics are now offering virtual visits and health services.

Promoting virtual health in rural Alberta communities makes sense, but it will require careful planning to select the technology and build the required infrastructure. The quality of internet and cell phone coverage is still poor in many rural areas, which makes consistent use of virtual health challenging. Health-care providers will also need to be trained to deliver virtual care properly. 

 Digital health literacy means that people understand the benefits and effectiveness of virtual health and have the knowledge and skills to safely use virtual health tools offered by their health providers. – Deloitte 2019

Equally important to health-care provider training is the need to build digital health literacy in the general population. Many rural Albertans use the internet to find health information, for on-line banking, and to connect with friends and families. However, chances are that few of them have had a virtual health visit. Perhaps virtual health options are not available in their community or the residents don’t know about the options. Rural residents might be suspicious of the online tools or not sure how to use them. It could also be that they do not trust the quality of virtual care they might receive.  

Educating patients and their families in digital health means they know about virtual health options available in their communities. They also learn how to use virtual health services and learn about the safety and quality of virtual health. It is important that residents feel comfortable with virtual health and feel that they can trust this new approach to care. 

 Six in ten Canadians feel they don’t know enough about digital health apps and services. – Health Infoway, 2021

Health-care providers play an important role in building virtual health literacy in their communities. They can inform their patients of virtual health services and show patients how the technology works. Community volunteers may also help patients and their caregivers to learn and adopt virtual health. 

A survey conducted by Canada Health Infoway in 2018 showed that a majority of Canadians seem to embrace virtual health options and would like to use virtual health tools more frequently.

Specifically:

• 71% of Canadians would like to be able to book electronic appointments
• 63% of Canadians would like to be able to email their health-care provider
• 41% of Canadians would like to have video visits with their health-care provider

The desire for virtual health options expressed by Canadians was in stark contrast to what health-care providers were offering at the time.

And then came the pandemic… The events of the past year have accelerated the use of virtual health dramatically.

In their latest study, Health Infoway consulted with almost 60,000 Canadians. Nearly seven out of ten Canadians that accessed health care had a virtual visit during the pandemic. Most of them were satisfied with their experience and would like to use virtual health options on an ongoing basis.

They reported several benefits of virtual health:

• Convenience – saving time and travel
• Safe – avoiding risk of exposure
• Control – better management of health
• Access – helping avoid walk-in clinic or emergency-department visits

Although there is a clear desire for virtual health, not all Canadians will embrace electronic access to care. Age, gender, education and rural/urban location influence how frequently the internet is used. This might signal differences in access (e.g., no internet available) or preferences and comfort level with online media. Policy makers, health systems, health providers, and communities will need to better understand these differences in order to create virtual health strategies that work for all populations. 

By 2046, one in five Albertans will be over the age of 65. Instead of placing more demand on long-term care facilities, the vision in Alberta is to assist the older adults with “aging-in-place.” This requires supports and infrastructure to enable them to live independently in their own homes.

While many of the older adults living independently report good health, others struggle with various chronic conditions (e.g., cardiovascular diseases, diabetes, or physical injuries due to falls and other accidents). These seniors are at risk of high-cost hospitalization or residence living with 24-hour medical care. Hospitalization also heightens the risk of functional decline and death in the older adults.

E-health solutions such as assistive devices, social networking, mobile communications, and remote monitoring are rapidly growing and are designed to assist older adults with independent living. Several solutions are currently being tested in Canadian initiatives. The Canadian Age-Well initiative is a network designed to create technology and services that benefit aging adults.

Below are two noteworthy initiatives in Alberta that use remote monitoring to care for patients:

• Eligible cardiac patients can have small electronic devices (i.e. pacemakers/defibrillator units) implanted. A monitoring unit allows transmitting data from the patient to the Cardiac Implantable Electrical Device (CIED) Clinic at Foothills Medical Centre. The team at the clinic can remotely access the patient’s device, recommend changes to medications and, most importantly, determine if emergency medical attention is warranted.

The program received the Patient Experience Award from the Health Quality Council of Alberta for this province-wide initiative.

• A brand new home monitoring initiative started in July 2020 in three central Alberta Primary Care Networks. Remote monitoring devices allow rural patients to record and upload data such as blood pressure or body temperature. The clinicians can view the data on a dashboard and can interact with patients and support them when needed.

The initiative is a collaboration between Alberta Central Zone Primary Care Networks (PCNs), TELUS Health, Boehringer Ingelheim (Canada) Ltd., Alberta Innovates, Health City, and Alberta Health Services.

Studies have shown that remote monitoring can reduced the number of visits to emergency departments for older adults and residents with heart failure. This leads to better care for the patients but also saves health-care cost.

Remote monitoring technology may be one way to help seniors in rural communities to live independently as it allows checking on the health of patients in their own homes. Reviewing the data remotely, clinicians can make quick decisions about care and can prevent deterioration in health status. Seniors only have to travel to specialist clinics when an urgent need emerges.

High speed internet access is a critical infrastructure to support continued growth and success of rural communities. It is important for doing business, especially with the increasing acceptance of remote work. It is important for school success, particularly when public health crises like the COVID-19 pandemic have required schools to move to online for short-term or long-term delivery.

High speed internet is also important for health care. Unreliable broadband internet at clinics, hospitals, or even in patients’ homes can make it difficult to access health records and or other electronic information like the latest research findings. It can also interfere with virtual health options like video visits with specialists.

In 2016, the Canadian Radio-television and Telecommunications Commission (CRTC) declared universal access to high-speed internet an essential service. The Government of Canada has programs under way to connect 98% of Canadians to high-speed internet by 2026 and all Canadians by 2030. The $1.75 billion Universal Broadband Fund supports high-speed internet projects to achieve this goal. It is designed to bring high-speed internet, defined as 50/10 Mbps, to rural communities.

Canada’s progress towards universal high-speed internet:

Rural Canada may get help from Elon Musk’s Starlink Project, a new high-speed satellite service. Starlink received the green light from Canadian regulators and is currently being pilot tested in some Canadian rural communities. At the end of November, Pikangikum became the first Indigenous community to get connected to Starlink. Members of the remote community hope the faster internet will remove barriers to access virtual health services and education.

Explore this interactive map to see national broadband internet service availability across Canada.

To conduct a speed test of your internet connection click here.

Alberta Health Services (AHS) strives to enhance health-care access for all communities across the province. It uses several virtual health approaches:

• Clinical Telehealth Services for professionals to use for appropriate clinical appointments, consults, and educational sessions. 
• TeleHome Care to monitor and collect patients’ health information in their home. 
• Pediatric TeleSurgery to improves access to specialized pediatric surgical services.
• Virtual Pain and Symptom Control/Palliative Radiotherapy Clinic to connect patients with a multidisciplinary consultation service. 
• TeleMental/Psychiatry Services that provide timely and specialized services in response to referral requests from rural physicians.  

A recent organizational review of AHS included specific recommendations for virtual health. 

 Recommendation 25: Review existing virtual health initiatives and consider development of a provincial plan to leverage virtual health technology to provide care across remote populations. – Alberta Health Services Performance Review, 2019 

In response, AHS will increase its focus on virtual health initiatives. This includes supporting the shift in care from hospital to home; improving access for small- and medium-size communities; and creating the right mix between virtual visits and face-to face visits. 

Virtual care can be an important tool to deliver accessible and culturally sensitive care to Indigenous peoples in rural and remote settings with limited local health care. Under the virtual care umbrella, there are a number of innovative technologies that improve access and enhance the quality of timely care.

Examples of innovative technologies that have been used in the Canadian Indigenous health context are:  

• Computer tablets for health providers to enhance their ability to access online clinical, public health nursing, and education tools for patients for whom they provide outreach care.  
• Telehealth, an internet-based videoconferencing technology, for health-care providers to assess patients and provide educational sessions and training. 
• Remote Presence Robotic Technology that consists of maneuverable robots (“Rosie”) and portable devices (“Doc-in-the-box”) that enable face-to-face encounters between patients and health-care providers over long distances. 

The Alberta Indigenous Virtual Care Clinic (AIVCC) was launched in 2020. The AIVCC serves individuals self-identifying as First Nations, Inuit and Métis and their families. Patients and their caregivers can receive consultations, usually within 24 hours, by phone or through their computer with Alberta-based physicians experienced in delivering culturally-safe health care and wellness support. This service is ideal for patients who do not have a primary care provider or those who would like to avoid a wait to receive a consult for a non-urgent issue.  

The clinic collaborates closely with other care providers to offer timely, culturally sensitive, medically appropriate care to Indigenous patients in Alberta. This is an example of innovation in the delivery of Indigenous centered health care to support health equity.

Here are some great resources for health providers on providing virtual care:

• Alberta Medical Association: Information on virtual health including 2 webinars, privacy considerations, virtual care tools, billing codes
• College of Physicians & Surgeons of Alberta: COVID-19 virtual health advice: covers virtual care options and tools, consent, documentation, billing and links to additional resources
• University of Alberta: virtual care support kit for physician preceptors and medical learners
• Doctors Technology Office BC: Virtual health toolkit to help physicians get started with virtual care
• Ontario Government 2019: The Playbook is intended to help Ontario Health Teams build their digital health plan and capacity
• Rural Health Information Hub: US National Clearinghouse has a rural telehealth toolkit including seven comprehensive modules on rural telehealth
• Canadian Patient Safety Institute: Resources for healthcare providers and leaders
• Digital Health Canada: a member-supported not-for-profit professional association that connects, inspires, and empowers the digital health professionals creating the future of health in Canada.
• Dr. Lyndsay Davidson, Stephanie Cheon, and Lynel Jackson at Queen’s University: e-Communication and Patient Care; interactive educational module
• Dr. Sharon Domb, Dr. Aviv Shachak, Dr. Shmuel Reis, Dr. Andre Kushniruk, and Dr. Elizabeth Borycki: Health Communication Management – Email with patients: Module is part of an AFMC–Infoway faculty development collaboration; covers basic principles around digital communication in a health care setting (video below). 

Here are some great resources for patients about virtual health options in Alberta:

• Canadian Medical Association: How to Navigate a Virtual Care Visit – Patient Guide
• Alberta Health: Learning about Virtual Care
• Alberta Health Services: Healthcare Video Visit Info for Patients &Families
• Alberta Health Services: Zoom Visits Info for Patients
• Canadian Patient Safety Institute: Virtual care podcasts and resources

Click the links below to explore interesting reads on virtual care:

• CMA 2019: Virtual Care in Canada Discussion Paper
• CMA 2019: The future of connected health care – Canadians’ perspective
• Virtual Care Taskforce 2020: Virtual care – recommendations for scaling up virtual medical services
• Deloitt 2019: Narrowing the rural-urban health divide
• Deloitt 2019: Atlantic Provincial Medical Association: Environmental scan on virtual care
• Information Technology Association of Canada (ITAC) 2018: white paper on the acceleration of digital health technologies with recommendations that address the public–private interface, procurement practices, privacy and security standards and broadband capacity
• Digital Health Canada 2017: Digital health Canada strategic plan 2017-2020