Release date: April 7, 2022
Catalogue number: 45-20-0003
ISSN: 2816-2250
Healthcare is a privilege that Canadians value greatly. However, virtual healthcare was a rarity before COVID-19. Immediately after the pandemic hit in March 2020, Canadians were forced to rethink how they access healthcare. Appointments that would usually have happened in an office were suddenly taking place by phone or video chat. Now, two years later, most health care is conducted virtually. The question is whether access to virtual healthcare will disappear when the pandemic ends. Our guest, Dr. Gigi Osler, joins us to explore the barriers to virtual healthcare, the changes we saw during the pandemic, and what’s being done to make virtual care permanent.
Tegan Bridge
Guest
Dr. Gigi Osler, Co-Chair of the Virtual Care Task Force created by the Canadian Medical Association, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada.
Listen to audio
Eh Sayers Episode 7 - Doctor's Appointment? There's an App for That! - Transcript
Tegan: Welcome to Eh Sayers, a podcast from Statistics Canada, where we meet the people behind the data and explore the stories behind the numbers. I’m your host, Tegan.
Tegan: Just curious. How long has it been since you sat in the waiting room at your doctor’s office? For many of you, I’ll bet the answer is something like, “Not since at least March 2020.” I’d never had a virtual appointment with my nurse practitioner until after the pandemic hit, but now, all of my appointments have been online. I have to say, it’s been a bit of a game changer. I don’t have to take time off from work to cross the city and sit in a waiting room. Of course, that’s just my perspective.
Virtual healthcare isn’t new, but COVID-19 pandemic fast-tracked its widespread adoption across the country. So, what are the pros and cons of virtual healthcare? And, is it here to stay?
Tegan: Could you please introduce yourself with your name and job title?
Dr. Gigi Osler: OK, and so I'm Dr. Gigi Osler and I am a Co chair of the Virtual Care Task force.
Tegan: Perfect. What is virtual healthcare?
Dr. Gigi Osler: That's a great question and I'm gonna answer that first by asking you a question. So since the pandemic started with your health care team, have you had a video visit with them? Have you had virtual phone call visit with them? Have you received any messaging via text or email since the pandemic started?
Tegan: I have actually. I've had a few UM telephone calls and I've also been communicating with them via email.
Dr. Gigi Osler: And so you have experienced virtual healthcare, and let me read you the definition for virtual healthcare that the virtual care task forces are using, and it's very similar to the definition that many groups are using.
So virtual healthcare: any interaction between patients and or members of their circle of care, occurring remotely using any form of communication or information technology with the aim of facilitating and/or maximizing the quality and effectiveness of patient care.
So very broad, but encompasses a lot. So it encompasses communications that may be secure email or texting. As you've had. It may be a phone virtual visit. It may be access to your test results via patient portal. It may be a video visit. So it's all of these different technologies and ways of communicating all brought under one broad definition of virtual care or virtual healthcare.
Tegan: And could you talk about how the COVID-19 pandemic affected virtual healthcare? What's the situation on the ground right now?
Dr. Gigi Osler: Think of the COVID-19 pandemic like a match. It just lit the adoption and acceleration of virtual healthcare across the country in ways none of us could have imagined. So the virtual care task force is a task force comprised of almost every medical organization in Canada that you can think of. And throughout 2019 we were looking at virtual care. What is it? What was it like in 2019? What were the potential benefits of it? What areas needed to be worked on? And then we released our final report in about February 2020. Mere weeks before the World Health Organization declared COVID-19, a global pandemic, and we couldn't anticipate, had no idea in 2019, when we were working on this, what would come in 2020 and where would we be at right now in 2022. So the pandemic really catalyzed the adoption, spread and use of virtual care, especially in those early days, when not much was known about the pandemic and much of healthcare switched to virtual.
And so I pulled up some stats on how much virtual care was being used and Canada Health Infoway said that in 2019 (and this is all healthcare provider visits) 10 to 20% of all health care provider visits were done via virtual healthcare in April 2020, so in the very early days of the pandemic, 60%. And I've seen some other numbers that looked at the rate in 2020 as high as 70% of all visits were virtual. Back down to 2020— Sorry 2021, and it was back down to about 40% of all health care provider visits being done virtually and it continues to be done virtually. And now we're seeing that integration of virtual care and in-person care and trying to figure out what is the path forward to integrate both types of care into sort of a comprehensive model across the country.
Tegan: The virtual care report was released February 2020. How would that report be different? Do you think if it released February 2022?
Dr. Gigi Osler: You know it— some would have changed, you know. Certainly the usage of virtual care across the country. Those numbers that we just talked about. Those would be different. Some have remained the same, and so in the last two years when we look at what have been the enablers of virtual care, you know, certainly the pandemic was a catalyst for it, made it happen. The ability of Canadians to be able to use our phones, use video platforms, email that has enabled virtual care.
We've also seen some of the barriers to virtual care, some of the barriers being technology. Not everybody has a smartphone not everybody has access to some of the technology like Zoom or MS Teams in order to do the video visits. Not everybody knows how to work it. Uh, and geography for one. You know, maybe you don't live in an area where there is reliable high speed Internet access. We don't have a lot of the regulatory and governance and policy changes that are needed. Much more work is being done on it now compared to 2020. But there's still a lot of work that needs to be done.
If you have an internet download speed of 50 megabits per second or more, your internet can support things like multiple users at a time, ultra-high-definition video streaming with more than one connected device, or downloading a high-definition movie quickly. According to the 2020 Canadian Internet Use Survey, for those respondents who knew their advertised Internet connection speed, 72% reported having these faster speeds. But there is a geographic divide between those who do and those who do not live in what’s called a Census Metropolitan Area or Census Agglomeration. These are areas like Ottawa-Gatineau, Montréal or Vancouver. Just over three-quarters of respondents living in these areas had that faster speed, compared with less than half of those living outside these areas.
Tegan: Are there any preconceived notions from either physicians or the general public about virtual healthcare that you would like to take this opportunity to bust?
Dr. Gigi Osler: Well, you know what, I'm gonna ask you that as well and I'll share with you some of the preconceptions or misconceptions that I've heard. But if you could transport yourself back to say January, 2020. Before the pandemic and somebody had asked you about virtual healthcare, in your mind, what would you have pictured?
Tegan: I'll be honest, it's quite similar. I have very few health concerns. I'm fairly straightforward, so for me all I wanted was just be able to call my doctor and get a prescription without having to go and wait in the waiting room. So that's all. That's all that I really wanted.
Dr. Gigi Osler: So prior to the pandemic, the Canadian Medical Association had dumped some surveys and asked the general population about virtual healthcare. What did they see as the benefit of it. And the majority that answered the polls said that they looked at virtual care as a tool that could help access care that could help people have access to specialists, their own physicians, would make it more convenient, and many thought it would make it more efficient. The younger you are, the more familiar you were with technology, the more likely you are to say, ‘yes, virtual care is something I want’.
Interestingly, across all demographics, people never wanted to lose that personal interaction in that personal touch with their health care team. So, no one wanted robots, you know, some people, when they heard virtual healthcare, thought that maybe that just meant you'd never see a real person. Maybe you would just have some type of AI algorithm which would walk you through your symptoms, give you a diagnosis. And so, and video visits was one you know.
People sometimes had this vision that it would be like the Jetsons. You know, for the younger audience, that's an old cartoon, but something really high tech. Interestingly, prior to the pandemic in the United States, there was, there is a big healthcare system called Kaiser Permanente and prior to the pandemic we had looked at what they were using for virtual healthcare and in their system the majority of virtual healthcare visits or touches was secure messaging. So secure text or email then telephone visits with their health care provider, so anyone in their health care team, and then finally video visits, if memory serves me correct, might have comprised about 10% of all of their healthcare touches. So where we weren't talking about, you know, fancy Jetsons video type visits we were talking about using the phone, texting or email.
So one preconception, certainly before the pandemic was that it had to be something very high tech and very fancy and so with that information, with the pandemic, everything that's been going on we, now know and I think a lot of the general population, patients’ health care providers are thinking that virtual healthcare has been such a boon. It's been a good thing to be able to continue to stay in touch with your health care team. But the path forward is really trying to figure out how do you incorporate that with real live in-person visits so that the future of healthcare in Canada really is more comprehensive, incorporates both, so sort of like a hybrid model so that we really can emphasize access to care, quality care, and safe healthcare.
Many Canadians don’t have a regular healthcare provider. In 2020, 14% of Canadians 12 and older reported that they didn’t have a regular healthcare provider. This number is even higher among those between the ages of 18 to 34, about 1 in 4.
Tegan: There are so many Canadians who don’t have a regular healthcare provider. Is this something that virtual healthcare could help with?
Dr. Gigi Osler: I really do think it could, and certainly before the pandemic when people were surveyed about what could be the benefit of virtual care, improved access to it was always cited as a benefit. Access to your own doctor, access to specialists. Let's say if you lived in a remote, rural, isolated or northern community that was seen, and still is seen, as a way to improve access. Part of what we, and when I say we, I mean anyone working in healthcare right now looking at the potential benefit of virtual healthcare in the future, need to always keep in mind; equity of access.
So while virtual healthcare has improved access in some ways, it's almost widened the gap and some will call the digital divide. So if you do have access and the knowledge and the technology and the skills to be able to utilize virtual healthcare, it's been a benefit, but we have to be mindful, especially as we move forward that not everybody has all of that and so making sure that virtual healthcare in are publicly funded Canadian healthcare system ensures equity of access is part of what we must consider moving forward.
Tegan: Could you talk about access to virtual care? Who does and who does not have access?
Dr. Gigi Osler: We don't let, let's have a conversation. Often when we talk about what defines health or what determines health, one term that is often used is the social determinants of health, which I know you're familiar with: income, food, access to clean potable water, housing. All of those are social determinants of health. Think of what are the digital determinants of health. And that’s an important concept that prior to the pandemic, prior to virtual healthcare, I hadn't really thought much about, but now I'm thinking more and more.
So what could be some of the digital determinants of health? Geography, where you live. Do you live in a remote, rural, isolated or northern community where you don't have the infrastructure to have reliable broadband access? What about your socioeconomic status? What if you don't have the smart phones or a desktop or a laptop that would let you access virtual healthcare? What about your language? Much of virtual healthcare is provided in either English or French, and there may be some that are provided in alternative languages, but it is still very much based, virtual healthcare is based in English and French. What about your technical knowledge? Do you know how to download Zoom or MS Teams, setup platform, work it that way? What about anybody who has a disability hearing disability, a visual disability? How were they able to access some of these platforms and systems? What about your housing situation? You know if you’re experiencing homelessness, how are you going to have a stable place where you can have regular virtual healthcare visits. So, I think, to answer that question about equity of access, some of those digital determinants of health really need to be considered as we start to design all of these new platforms and systems.
Dr. Osler is right. Equity of access is still an issue. For example, in 2016, seniors were the age group most likely to have had contact with a medical doctor in the 12 months prior to being surveyed. However, seniors as a group had more negative views on the benefits of technology and were less likely to be Internet users. 97% of Canadians aged 15 to 64 used the Internet in 2016 versus 68% of seniors.
Tegan: So many Canadians reported not accessing all of the mental health care they need because they were too busy. How does virtual healthcare invite us to reimagine the role that healthcare plays in our lives?
Dr. Gigi Osler: Let me start by saying mental health is physical. Health is health. And mental health, if we take a step back under the Canada Health Act, isn't as well covered as physical health, so that's, you know, even before virtual healthcare, that's still a barrier to health. Mental health visits, so mental health care provided virtually, has been shown during the pandemic to be very effective. As effective, in some cases, as in-person care, so certainly mental health is one of those medical conditions that really can be very well suited to virtual healthcare. Think part of the answer to that question is really expanding? How our governments think of health? And in the future, wouldn't it be nice if we could have more mental health supports, psychology, counseling, therapy, covered under the Canada Health Act so that more people could be, would be able to access it and not have the costs or ability to access it as a barrier.
In 2018, roughly 5.3 million people in Canada mentioned they needed some help for their mental health in the previous year. Just over half of these Canadians had their needs fully met.
Tegan: What role could virtual healthcare play in providing Canadians with support for mental health needs?
Dr. Gigi Osler: I look at virtual care really having that potential to support mental health across Canada. I remember visiting when I was president of the CMA, visiting some of our Northern territories, and say even just psychiatry, few or no psychiatrists in the territory, so access to psychiatric care, which is covered under the Canada Health Act, would be limited. But imagine if you lived in a northern community but could have access to a psychiatrist, or if we even have a bigger vision, a psychologist or a therapist who lived in a different province. So that you could have a virtual visit with your mental health care provider. That, to me, really speaks to the vision of better health care and better access to care, especially for something like mental health, which we know, is well suited to virtual healthcare. So, I see the potential and possibilities in so many aspects of health care, with mental health being one of them.
Tegan: 20% of those with an unmet mental health care need reported that language problems and help not being readily available were a barrier to accessing care. Have you ever experienced a time where virtual care eased a language barrier, or where it could have?
Dr. Gigi Osler: Let me give you a real life example from my own work where we have been able to overcome some language barriers with virtual care, so as you said, and as Canada becomes more multicultural, we are seeing more and more different languages being spoken in Canada. And if we receive a referral for a patient whose first language isn't English and whose primary language is something other than one in which I'm able to converse, and we can set up in advance an interpreter of the language of their choice, who then facilitates a 3 way conference call between myself, the patient and the interpreter, which has been extremely helpful, and we’re able to do that for in-person visits as well, again, if we are given that information ahead of time by the referring provider to say, “hey you know this person’s first language is Mandarin”. So through interpretation services provided by our health authority, we've been able to do that quite well with the virtual phone visits that I've been doing and it's something that I think really can help improve access for those whose English isn't their first, their first language, and you're absolutely right in the hospital, interpreters are available and can be arranged in advance.
But sometimes, if it's middle of the night, it would be, maybe difficult for you to find somebody and sometimes in that situation in a hospital you'll hear paged overhead. You know anybody speaking Arabic, you know? Please call such and such a number so it can be made more accessible for people speaking different languages and that I think is part of the recognition that as a multicultural country when we want to provide equitable access to health care, language is certainly one of the things we must consider.
Canada continues to have a hospital-centric care system for those who are dying, despite the preference of most individuals to die in their community and other home-like settings. In 2020, 55% of deaths in Canada took place in a hospital.
Tegan: What role, if any, could virtual healthcare play in palliative care and empowering more Canadians to make decisions about end of life care?
Dr. Gigi Osler: That's an interesting question, and I'll be honest, I haven't looked into the literature about virtual care use in palliative care. I definitely see the possibilities and I can see one possibility in the ability to bring together multiple people within somebody's circle of care, so that person, their caregivers, their families. Bringing them together virtually to have some of those discussions, where in the past, perhaps some of those discussions would have taken place in person, so family visits where, maybe if there was a child or a partner who didn't live in the same city, might not be able to participate. So in that setting, I think the possibility of virtual care as enabling interactions between different people involved in someone’s circle of care who might live geographically distant. It would certainly be an opportunity to bring people together to participate in those discussions and what more important time than perhaps once somebody is receiving palliative care or at the end of life.
Tegan: Could you talk about a procedure or medical intervention that could not have succeeded without virtual healthcare?
Dr. Gigi Osler: Oh, that's a good one so… A specific procedure or medical intervention. Well, I know of colleagues who have given me examples over the last two years. And I'll give you the example of, say, a physician working in our remote community who was able to communicate with a specialist, send them information about the patient, have the specialist interact, perhaps via phone, with the patient in order to be able to figure out and diagnose what that patient’s condition was and really determine if that patient needed to be transferred out or managed by the physician in that remote community. So that's one example of it, and I know there's probably many more.
Tegan: What are some of the barriers that could threaten the permanent, widespread adoption of virtual healthcare?
Dr. Gigi Osler: We knew prior to the pandemic starting there were policy barriers, there were legislative barriers, there were regulatory barriers. Many of those are being worked on by different federal, provincial, territorial, tables and committees and groups, but there's still fairly significant ongoing work that needs to be done.
We've seen an explosion of virtual care across the country and different systems, different platforms, different portals, many of which are still siloed and don't communicate with each other. I had a conversation once with a physician colleague who worked in Toronto, who worked at a few different hospitals who had something like 4 different hospital systems. So digital, like virtual healthcare systems, but none of them spoke to each other. So if you're at one hospital there's no way for that hospital system to communicate with another one, so there's not a lot of interoperability between some of these different systems and platforms.
Access is still an issue for many Canadians who don't even access to your own health information. So some provinces, some hospitals may have patient portals where you, as a patient, can access your information. That's not widespread across the country. Many tests and information, so patient results, might not be in a digital ready format, so, you know, how do you share that information when it's still, you know, maybe on a paper. It's not in a digital format. We still don't have sort of this overall pan-Canadian governance framework to ensure that the virtual healthcare that's being conducted in Ontario is the same as the virtual healthcare in Prince Edward Island. So there's still uneven levels of access, quality of virtual healthcare across the country and so multiple different things at play.
But I think really, you know, if we look at what is the outcome that we want to have from virtual healthcare across Canada, safe healthcare, quality health care, effective healthcare, healthcare that you can access virtually regardless of, you know, your knowledge, skills, socioeconomic status. Maybe even the health care that you can easily use across the country, so one that's portable so that, let's say if I moved from Manitoba and Winnipeg to Quebec? My Quebec healthcare provider, wouldn't it be nice if they could have access to my Manitoba health care records? so that accessibility and portability of health information. Uhm, I don't know if I said enough or it’s too much, but those are, those are just some of the things I came to the top of my mind.
In 2020/2021, while an estimated 858 people migrated from Manitoba to Quebec, the most popular province for Canadians to migrate to was BC.
Tegan: Is there anything that I didn't bring up that you'd like to discuss?
Dr. Gigi Osler: I'm really excited to have this conversation because it's as we come out of the pandemic and I'm putting my hopeful, optimistic hat on. I know across the country every province and territory is dealing with different levels of the pandemic. But as we start to come out of the pandemic, I'd like many of us to just start thinking, you know, health care providers, patients, governments, health authorities. How can we make our healthcare system better? You know, we're seeing the healthcare system under strain across the country. Many health care providers are using virtual care. How can we take the lessons we've learned from the pandemic and virtual healthcare, the benefit we've seen from virtual healthcare, how can we incorporate that into our system? To improve everybody’s health as this pandemic recedes and gets better.
So I think that is my thought and my hope, you know, that people, patients keep having these conversations, keep talking about what they would like to see, how they like to see their care with their health care team, continue to improve in the future. And as health care providers, you know, we're continuing to learn and adapt to try to make the healthcare system better. If there is one silver lining from this pandemic, please let it be that we will incorporate virtual healthcare into in-person healthcare in our publicly funded healthcare system.
Tegan: K, If someone would like to learn more about your work or virtual healthcare, where should they go?
Dr. Gigi Osler: The report from the Virtual Care Task Force, the one that I'm a co-chair of, is freely available to the public on the web, and you just have to go to cma.ca and search out Virtual Care Task Force. Or you could probably Google Virtual Care Task Force. Canadian Medical Association. The link will pop up and the report is available as a downloadable PDF in both English and French.
Tegan: Perfect thank you so much. Thank you so much for joining us.
Dr. Gigi Osler: Thank you for having me. It's been a pleasure.
Tegan: You’ve been listening to Eh Sayers. Thank you to Dr. Gigi Osler for taking the time to speak with us.
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