Prior to COVID-19, the only telemedicine service eligible for OHIP coverage came through the Ontario Telemedicine Network. But in March, the Ministry of Health introduced temporary billing codes, enabling health-care providers to bill for virtual care on whatever technology they chose to use.
That sparked a “profound acceleration” in the adoption of digital health technologies in Ontario, says Brett Belchetz, CEO of Maple, which provides 24/7 access to primary care through instant message, audio, or video.
Now, the province is increasingly funding projects in collaboration with private companies — all provided through OHIP. For example, long-term-care patients can access a specialized physician from Trillium Health Partners in Mississauga via Maple’s platform. Trillium is also providing on-call coverage for long-term-care residents, who previously would have had to go to the emergency room.
Belchetz says Maple was discussing the program with Trillium before the pandemic, but it was part of a long decision-making process. “Until March, virtual care was something the province was doing in a way that did not allow work to be done by private companies in any meaningful way,” says Belchetz, who is also an ER doctor in Scarborough.
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“While virtual care was of interest to the provincial government prior to COVID-19, there was little urgency to make investment decisions. That has changed dramatically, with our government now willing to make decisions on programs, such as the long-term-care initiative, in weeks rather than years.”
This shift is a long time coming. The Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada created a national task force last year to determine why Canada had fallen behind in adopting virtual care. Its report, released in February, said it would take years for Canada to achieve an adequate level of virtual care due to such issues as limits on patients’ electronic access to health records, a lack of safety and quality standards, and a lack of provincial compensation for doctors providing virtual care.
Meanwhile, the private virtual care industry was growing. “The technology is here, and it is being used in mostly the private system,” task force co-chair Gigi Osler said in a panel discussion in February. “If we don’t think of innovative ways to bring this technology to the public health-care system, we’re only going to see the gaps increase between those who can afford it and those who cannot.”
Only about 4 per cent of Canadians had received virtual medical care, excluding phone service, prior to the pandemic, according to Canada Health Infoway. By June, a CMA survey showed that 47 per cent of Canadians had received virtual medical care since the start of the pandemic — by phone, text, videoconference, email, their provincial telehealth service, or a private virtual health provider.
Darren Cargill, the medical director at Hospice of Windsor and Essex County, is new to providing virtual care. Pre-pandemic, he spent several hours each week driving to visit palliative-care patients in their homes. He says his work may never look like that again.
“We were forced to switch to virtual care overnight, and it has completely turned our practice on its head, but in a good fashion,” he says. “We had the capability to do virtual care before, but we dragged our feet, because we thought patients and families wouldn’t like it.”
Now, he says, “we give patients the option of virtual or in-person visits, and many are choosing virtual. So we are able to see more patients and have more frequent contact with patients. About 70 to 80 per cent of our home visits are now virtual.
“Having choice is good,” he says, but “we need to ensure interoperability, to make sure we can exchange information and have the ability to work together. We don’t want to create a set of silos. But if this serves patients — and they like it — more people should get on board.”
The Ministry of Health says it’s moved virtual care up on its priority list. “During the COVID-19 pandemic, the government prioritized virtual care to ensure the people of Ontario would have access to physician visits with physical distancing measures in place. Moving forward during the re-opening phase of the pandemic, access to virtual care remains a priority,” it said in a statement.
Danyaal Raza, board chair of Canadian Doctors for Medicare and an assistant professor of family medicine at the University of Toronto, hopes the province will proceed with caution. “Progress on virtual care has made leaps and bounds since the pandemic. In Ontario, it has moved from a largely uninsured, to an insured service. This is a positive move,” Raza said in an email. “However, many companies offering virtual care continue to charge patients to access care, for elements of their care purported to be uninsured by OHIP. This is very problematic. Many patients may not understand the difference between insured and uninsured services, and falsely believe they must pay to access care. If this confusion continues, it will disproportionately impact low-income Ontarians and constitute a violation of the Canada Health Act.”
Karim Keshavjee, program director of the Master of Health Informatics program at the University of Toronto’s Dalla Lana School of Public Health, separates health-technology companies into three categories: companies that provide a tool as opposed to a service, companies that provide a service, and companies that collect and analyze data. He says the highest level of concern should be reserved for the last type: “This is an area of high risk, but from what I can see, Canadian hospitals and organizations are treading very carefully here.” He says working with the private sector is a “two-edged sword,” but that there is little risk of abuse in Ontario yet.
Meanwhile, innovation is happening quickly. Toronto-based InputHealth has an online tool that allows patients to take the COVID-19 self-assessment. They can then be virtually connected with a primary care provider if they require follow-up. InputHealth signed a procurement deal with the Ontario government in roughly one week — typically, experts say, this process could take months or years.
“Health-care systems must be able to evolve and adapt quickly to major public-health issues. This requires widespread availability of versatile, dependable, modern tech that's secure and easy to use,” Jasmin Ramsey, director of media relations at InputHealth, said in an email. “The speed of our deployment and overwhelmingly positive response showed Canada can and should embrace solutions like this going forward.”
“Procurement processes can take years and make it impossible for smaller start-ups to be successful,” says Belchetz. “I am hopeful that, as we move forward, there can be a happy medium. A process that allows many parties to know there is an opportunity and ensures the government is getting the best value but isn’t so onerous that it ties you up for years or you need to be a multinational corporation to have a chance.”
In a statement, the Ministry of Health told TVO.org that the provincial government is committed to reducing regulatory burden: “The COVID-19 outbreak has reinforced this as a government priority.”
Procurements are “very thorough and can take a very long time,” says Ed Brown, CEO of the Ontario Telemedicine Network. “When you are spending the public’s money, you want to give them confidence that you are spending it as wisely as you can. But we are trying different ways to improve the process.”
For example, the government now has vendors of record that have a procurement arrangement authorizing them to provide goods and services for a defined period. This means a hospital could use one of the government’s vendors of record without going through the bidding process.
Belchetz is also hoping to hear that virtual fee codes — set to expire in March 2021 — will be extended. This, he says, would motivate start-ups to increase investment in innovative technology.
“I can’t speak for the government, but the genie is out of the bottle now,” says Brown. “I don’t think we will go backward. It will be interesting to see how this evolves over time.
“I have been involved in virtual medicine for many years. I thought it would be adopted quickly. I was very wrong. But then, almost overnight, it’s become mainstream. Soon it will just be part of our health system. They won’t call it virtual health care — it will just be health care.”