If you were to walk into a doctor’s office complaining of stomach pain, a couple of things might happen. First, your physician might ask a few questions about the location and intensity of the pain. They might also consider your age, diet, and lifestyle. Eventually, they will put their hands on your belly, press down, and feel for the source of the pain.
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That last step—known as palpating the abdomen—might feel less familiar after nearly two years of COVID-19 restrictions. So might walking into a doctor’s office at all. Since March 2020, in addition to popularizing remote work, online education, and Zoom celebrations, COVID-19 has brought a massive shift in the way we interact with our health care system. In the first days of lockdowns, clinics, medical associations, and governments across the country scrambled to minimize face-to-face interactions between doctors, nurses, staff, and patients.
The cumulative effect of these changes has been enormous. In 2018, only 8 percent of patients reported having had a virtual visit with their health care provider, according to the Canadian Medical Association (CMA). Since the pandemic began, that number has shot up to about half.
A virtual doctor’s appointment typically takes only fifteen minutes, while travelling to a clinic, paying for parking, and waiting around can take hours. The shift to virtual care could lead to better access for people who don’t have paid time off, people who live in remote communities, and people with disabilities. For residents of long-term care facilities, telemedicine and assessing early symptoms can decrease the chance of down-the-line hospitalization, which can be exhausting and comes with its own risk of catching a dangerous infection. Several virtual “emergency rooms” have also popped up in parts of the country. Patients worried about urgent but non-life-threatening issues, like sprains, stings, and sinus infections, can sign up online, get a link to a video call, and speak with an ER doctor the same day, without clogging up waiting rooms.
Many of these changes are here to stay. This summer, a survey by the CMA and Canada Health Infoway, a federally funded not-for-profit organization that works to accelerate the adoption of digital care, found that the majority of physicians plan to keep using this type of care once the pandemic has receded. In Ontario and British Columbia, the provincial governments are negotiating the payment systems that will allow doctors to continue charging for virtual visits. Other provinces are expected to follow suit.
A future where you get to talk to your doctor on your lunch break instead of languishing in a stuffy waiting room, dodging the coughs of other patients, sounds convenient. But it also comes at a price: since the transition to virtual, some patients believe their quality of care has decreased. According to the CBC, the College of Physicians and Surgeons of Ontario and the province’s patient ombudsman have both received complaints from patients saying that their doctors refuse to see them in person even when their illnesses are difficult to assess over the phone. One mother recently told the CBC that her one-year-old son had received a misdiagnosis after his doctor heard his cough over the phone.
For those who were studying virtual care long before the pandemic, this comes as no surprise. Finding the balance between convenience and improved access, and determining what must be addressed in person, will be among the biggest challenges ahead. “You cannot diagnose appendicitis or a mass over the phone,” says Sacha Bhatia, former director of the Women’s College Hospital Institute for Health System Solutions and Virtual Care, in Toronto. “If you have a patient with abdominal pain, you can get a history. But, at the end of the day, you do need to examine the abdomen for lumps and bumps.” Experts say Canada has been lagging behind other developed nations on virtual care for years. If virtual care is going to be a more prominent part of our health care experience, they say, governments and health care professionals will need to have important discussions about quality of care, compatible technology across clinics and hospitals, and changes to workplace culture in the medical field.
The rise of virtual care has resurfaced old debates about how medicine operates in this country, including what exactly a doctor is paid to do, what quality care actually looks like, and how best to help those who have the least access to care. If governments, professional associations, and clinics can get it right, a digital approach could mean shorter wait times for specialists, identifying symptoms before they become serious, and easing the anxiety that comes with waiting weeks or months for a diagnosis. It could also give more Canadians access to a family doctor. In other words, it may be an opportunity to bring health care back to its true focus: the patient.
Canada was an early leader in offering health care from a distance. In the 1950s, radiologist Albert Jutras experimented with sending X-ray images between Montreal hospitals. Two decades later, Arthur Maxwell House, a neurologist at Memorial University of Newfoundland, used the telephone for consultations with patients in isolated parts of the province. The university also worked with NASA to launch Hermes, a satellite that allowed the Health Sciences Centre in St. John’s to transmit audio and video to a hospital about six kilometres away.
Since then, the country has fallen behind. In a 2020 report by the Commonwealth Fund, which surveys patients and clinicians in eleven high-income countries, Canada ranked below average on all four global comparisons of quality of care. Compared with those in the US and Norway, Canadian patients were less likely to access their lab results online, email their physicians with questions, or book remote appointments. Norway has been in the process of digitizing its health care since the early 2000s. Today, despite a decentralized system where health care is managed locally rather than by the central government, the country has integrated virtual medicine into almost every aspect of care: any physician can log in to a universal electronic record system and see a patient’s history even if it was taken at a different clinic, and electronic communications are used for referrals, requests for labs or radiology services, and sick leave. The US boasts the Kaiser Permanente system, which is considered a world leader in the virtual health field, though it is funded by monthly premiums. Kaiser covers 12.5 million people, many of whom can securely message their doctors about their concerns—a touchpoint many Canadian clinicians don’t get paid for.
In Canada, a lack of information exchange and coordination within provincial health care systems has been an issue since well before the pandemic. Clinics and providers use different systems to store electronic medical records, which means a family doctor and a local emergency room may not have the same background information on a patient, including their history and a list of their daily medications. None of this will come as a surprise to anyone who has had to manage multiple log-ins to different online charting systems, repeat their history to yet another nurse or doctor, or call a clinic to ask whether staff received a faxed referral. The problem is further exacerbated across provincial lines. At best, this lack of interconnectedness leads to patients repeating their stories to each new professional they see or having to redo tests, which further burdens the system and increases costs as staff chase down records. Care is then based on incomplete information: patients try to remember which vaccines they received and GPs try to figure out what happened during an emergency hospital admission. At worst, serious symptoms or dangerous interactions between medications can be overlooked. On a larger scale, an absence of connectivity could lead to a virtual system even more fragmented than what we had before.
A report from February 2020 predicted that this kind of fragmented or “episodic” virtual care could wind up increasing visits to facilities where doctors still have to see patients in person, like emergency departments. While it hasn’t been extensively studied, anecdotal reports bear this out. Physicians say they’re frustrated with virtual care’s unintended side effects, including incomplete or misleading diagnoses. Raj Waghmare, an Ontario emergency doctor, says more and more patients are ending up in his ER after being prescribed antibiotics or other drugs without an in-person examination. When someone finally looks into their ear or palpates their abdomen, it becomes clear that the initial diagnosis was wrong. In September, the College of Physicians and Surgeons of Ontario confirmed that emergency departments have seen a “significant increase” in the number of patients who would normally have received care elsewhere, and that specialists are getting referrals for patients who never had a physical examination to determine whether they needed the referral in the first place. Outcomes like this can obscure the fact that virtual care was supposed to make our health care more efficient, not less.
For virtual medicine to be efficient—and safe—patients need to have a main point of contact, such as a family doctor, that they do visit in person from time to time. But, in 2019, 14.5 percent of Canadians didn’t have a regular doctor, with the highest percentages in Quebec, Saskatchewan, and Alberta, according to Statistics Canada. Even for people who have a family doctor, there are limits to what can be diagnosed virtually.
As doctors and provinces continue to discuss what a more permanent virtual care model—a new part of our universal public health care system—might look like, pay-for-service apps have leapt into the fray. Canadian health care startups raised more than $300 million (US) in 2020, roughly double the amount they did in 2019, according to the Globe and Mail. While most people in this country rely on public health care, these services charge a premium to connect patients with clinicians, registered nurses, and pharmacists, as well as to access their own health data. Yanick Beaulieu, a Montreal-based cardiologist who has worked in the virtual care space for years, has decried the shift to a corporate-driven approach as the “Netflixization of health care”—where patients pay for a monthly “all-you-can-consume” subscription and access as much health care as they want. While it may seem counterintuitive, more medical attention can be harmful to our health, increasing patient anxiety, unnecessary scans and tests, and the use of medications that can stress organs or cause other issues.
Billing for services that would normally be offered for free, like medical notes or requests for lab tests, is even more troublesome, argued physicians and University of Toronto professors Sheryl Spithoff and Tara Kiran in an op-ed for the Globe and Mail. They point to some platforms that even include in-app advertisements for drugs while patients wait in virtual “exam rooms.” (One example of this is Juno, an electronic medical-record system that is used by 376 clinics around the country.) Several studies show that advertising drugs directly to patients leads them to request and receive prescriptions that are either unnecessary or more expensive than the alternatives.
Then there’s the question of privacy. While the technology companies that provide these virtual care platforms and apps won’t sell sensitive personal information, Spithoff and Kiran write that they can hand over de-identified primary care records, information that pharmaceutical sales representatives can use to figure out which physicians to target to promote certain drugs. One such company, MCI Onehealth, estimates that de-identified electronic health records can be worth anywhere between $35 and $330 each.
The communities that virtual care was originally designed to help become precisely the ones left behind.
A two-tier model, where some with means pay for the care they need while others in underserved communities struggle to find a consistent doctor, goes against the very notion of equitable publicly funded care. Worse, the communities that virtual care was originally designed to help become precisely the ones left behind. Reports and surveys from before and during the pandemic have consistently found that people living in rural areas and those with lower household incomes face barriers to accessing online care. People in rural areas across Canada often do not have the same internet access as those in urban centres, for example, and a glitchy video call is far from ideal for showing a doctor a suspicious mole or talking about anxiety regarding a new medication. According to Infrastructure Canada, just 41 percent of households in rural communities have access to download speeds of at least fifty megabits per second and upload speeds of ten megabits per second—the minimum target set out by the federal government.
In Indigenous communities, which provincial health care systems have long underserved and discriminated against, some types of virtual care may not be reaching patients. In Nunavut, for example, the maximum internet speed currently possible is fifteen megabits per second, nowhere near the government benchmark. Researchers who study the uptake of digital health in Indigenous communities also suggest that simply applying the same technology to different groups likely won’t result in the best care. Instead, they say, collaboration with Indigenous leaders and youth—and cultural understanding of each community—is what will offer patients a sense of safety and keep them coming back. “Indigenous ways of knowing and being are protective determinants of health,” said Sarah Funnell, the founding director of the Centre for Indigenous Health Research and Education, in a September keynote speech on virtual care.
Even more basic than a reliable internet connection, access to a phone is often a prerequisite for virtual care. In the early days of the pandemic, when most appointments were suddenly conducted over the phone, Surkhab Peerzada, former co-chair of a digital health equity working group at Toronto’s South Riverdale Community Health Centre, and her team organized a drive to get cellphones into the hands of those who couldn’t afford them. She worries that a more permanent shift to virtual-first health care will put lower-income patients at a significant disadvantage. Community centres can hand out only so many cellphones, she says. Many patients also don’t have a private space to take a virtual call with a doctor: people who live in crowded or shared dwellings may worry about being overheard while having intimate discussions about their physical or mental health. Having new technological capacities to provide secure health care services over a phone or online—and even placing that technology in the hands of the people who need it most—doesn’t solve the whole issue.
Beginning last year, the Canadian Medical Association’s Virtual Care Task Force set out to identify the barriers to improving virtual care in Canada. “The horse has left the barn and we’re scrambling to put on the saddle,” said co-chair Gigi Osler in an interview with the Canadian Medical Association Journal.
With provinces and territories administering their own health care, each jurisdiction can choose to pay their medical staff in different ways. For example, in the Northwest Territories, doctors receive an annual salary no matter how many patients they see. In Ontario, on the other hand, physicians receive fees per service—for each checkup, each procedure, and, as of 2020, each phone or video call. But, if every service is paid differently, doctors must consider how they spend their time. How much is a video visit worth compared to a phone call? And how much is a physical examination worth? This, many experts say, is a vital part of our collective conversation about virtual care.
Ewan Affleck, Osler’s fellow co-chair, says it’s crucial to focus on these bigger questions around how we regulate health care, particularly the way it’s broken up along provincial lines and the way legislation makes it difficult to share patient data. The task force envisions a pan-Canadian approach to virtual care—one where a patient in Yellowknife can share their data with a specialist in Calgary; one where that patient knows that their family physician, their radiologist, and the walk-in doctor they saw last week are all part of the same circle of care. True virtual care, Affleck says, would involve a whole ecosystem where the patient and all their medical professionals have access to scans, test results, prescriptions, and other data.
In British Columbia, Saskatchewan, and Ontario, a patient can easily go online and check the results of a blood test conducted at a LifeLabs clinic just a few days earlier. But what if they had one test done at a LifeLabs clinic and another at an emergency room? And what if they make a third visit to their family doctor for a diagnosis based on those results? They would likely have to call three different clinics to consolidate all of this information just for one medical issue. This is what Affleck means when he says that medicine today is largely practising “analog health care in a digital world.” What governments have done, he says, is create fragmented sets of patient data that are designed around professional groups and geographic regions rather than around the patient, which has an immense impact on the quality of care a patient receives. While in the Northwest Territories, in part as the region’s chief medical information officer, Affleck spent seventeen years rolling out a project to solve this issue: a single patient chart shared by all physicians and nearly all health care providers for its population of approximately 45,000 people distributed over thirty-three communities.
While ambitious, he believes a similar system could be implemented across the country. And some groups are trying: in 2019, Canada Health Infoway, the organization that has been working to encourage virtual care across the country, launched Access 2022, an initiative intended to increase Canadians’ access to their health information. There are also changes coming at the jurisdictional level. Alberta Health Services, for one, is in the process of deploying an integrated clinical information system called Connect Care for all its facilities and staff, which provide about 30 percent of provincial health services.
The Virtual Care Task Force made a number of specific recommendations. One suggestion is to create a nationwide patient registry, which could involve assigning a numerical ID to each Canadian, where all a patient’s data would be stored, following them wherever they went—an idea simpler in theory than in practice. The task force is also encouraging provinces and professional associations to develop permanent fee schedules for virtual care appointments and create standardized recommendations around when and how to see patients remotely or in person.
For Sacha Bhatia, now an executive at Ontario Health, his favourite analogy about the future of virtual care comes from banking. If you want to pay a bill, he says, you know that you can do so on your phone or on your computer. But opening a mortgage, most customers understand, will require a visit to the branch. The key point here is that it’s the customer who understands the guardrails of the system, not just the bank employee.
Patients are already beginning to grasp this. You may intuitively know that you can refill your prescription over the phone. You may also know that a lingering stomach ache means a medical professional needs to check your belly with their hands. But you should be able to trust that you can get that if you ask for it. In this scenario, the patient is no longer at the mercy of a health care system that decides for them. In this scenario, everyone gets to decide what they need to be well.
