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Scaling up virtual care 2.0

The seismic impact of the COVID-19 pandemic on how health care is delivered, shifting seemingly overnight from in-person to virtual care, is likened to driving a car.

“We went from zero to 70 really fast,” says Dr. Sacha Bhatia, a cardiologist at Women’s College Hospital (WCH), an OSSU collaborator, and Director of the Institute for Health System Solutions and Virtual Care. “We went from less than 1% of care delivered virtually to about 70%. However, it won’t stay there. I think it will be in the 40-50% range that makes sense.”

Despite significant investment by the federal and provincial governments in digital infrastructure to support virtual care before the pandemic, there was limited adoption. The cost of visiting the doctor was born by the patient – time, travel to the appointment, parking, transit costs – and there were limited incentives for physicians to change. Until the COVID-19 pandemic changed everything.

“It shifted costs of contact to the patient and provider and institution,” says Dr. Bhatia. “Now we need infrastructure to screen, we can’t put people in a waiting room as it could spread infection. The risk of infection goes up and cost for PPE goes up so now the material cost is born by health system.” That change, combined with new billing codes that allowed physicians to be paid for digital care delivery, accelerated the switch to virtual care.

He sees enormous opportunity for OSSU to fill some of the research gaps to deliver virtual care in a broader way, such as understanding clinical workflow and optimal user design, quality of care and cost-effectiveness, equity and access, and the impact of virtual care on vulnerable people. This deeper understanding is necessary as we move into digital health 2.0 where the experience will be more in-depth and tailored to patient health needs.

While digital care is part of many hospitals, it isn’t yet linked into a larger framework in the health system. With its network of research centres, access to data analytics and skilled researchers, OSSU can create a multidisciplinary community of practice in digital care.

“The challenge is we need research to generate evidence on what works and what doesn’t,” says Dr. Bhatia. “OSSU can build a community of people doing research in this area that will fundamentally change the way we deliver care going forward.”

Changing behaviour

Getting people to adopt new technologies and change behaviours to move to a large scale is something Dr. Bhatia’s colleague, Dr. Noah Ivers, knows all about. As a family physician, OSSU IMPACT Awardee and Canada Research Chair in Implementation of Evidence-based Practice, Dr. Ivers works with health organizations to determine what interventions work to advance health, why, and for whom.

“Working side by side with Sacha and his Digital Health team, our Implementation Science team helps think about how we can get health professionals and patients to engage in the behaviour they want them to do, which requires thinking systematically about behaviour change,” says Dr. Ivers.

In partnership with OSSU, Dr. Ivers hopes they can be a resource for researchers who have digital solutions to deliver virtual care that are under-utilized.

“When people have promising initiatives to spread and scale, we want to be there to help them think it through,” he says. “We can be there from the outset, advising on how to build crucial implementation science questions into their research application, helping them collect relevant data, and then supporting them to interpret their findings in light of broader evidence from the implementation literature.”

His team is already involved in a variety of projects with virtual or digital care, designing how the intervention is rolled out. Patient partners play a key role in these projects, from describing preferred ways for physicians to speak with patients about digital interventions, to informing preferred outcomes to determine success.

“With virtual care, whether we are talking about asking a doctor to recommend an app or to use novel technology to interact with their patient or with another physician, these things all require behaviour change,” he says. “We need to use structured, thoughtful approaches to implementation, informed by behavioural science. Otherwise, the inverse care law will occur: people who really need it won’t get the novel treatment but those who might have done fine anyway will get access. We need to find ways to overcome barriers to use so that those who can most benefit can actually advantage of novel treatments and models of care”.

Working more closely with OSSU in the future, Drs. Bhatia and Ivers hope to provide the resources and expertise to help embed patient-oriented virtual care in the province’s health system.