“A win-win for patients and care providers” — that’s how Toronto’s St. Joseph's Health Centre describes the virtual-care options that have been increasingly available since the pandemic began. Health-care providers emphasize the greater access they afford seniors and those with mobility issues. A poll from the Canadian Medical Association, conducted in May, found that nearly half of Canadians have consulted a physician online and were “highly satisfied with the results”; many believed that further expanding access would benefit patients and improve health outcomes.
But Ann Heesters is worried about those being left behind.
“When we celebrate digital health — and we should; I think it’s been terrific — I am also thinking about who is left out of this equation,” says the director of bioethics at the University Health Network. “It’s the digital divide. There are actually many divides, based on generation, geography, gender, wealth, educational background. Virtual health care is not the same experience, depending on where you sit.”
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Access to virtual care, she says, can be limited by poverty, homelessness, technological literacy, or lack of Wi-Fi access: a woman living with domestic violence may not have the privacy necessary for a video call; a patient with an acquired brain injury could have difficulty following directions over the phone.
Don Seymour sees situations like these every day. He is the executive director of Wesley, a non-profit that provides support for people in Hamilton experiencing poverty, homelessness, and other barriers in the community. “Virtual care has been a huge boon to our society, but it is something that is often not accessible to people who have limited means or may have disabilities,” he says. “When you’re on the street or you’re getting $700 a month from the government, an iPhone is prohibitively expensive. So I think technological literacy is the big issue of our time.”
In the spring, Wesley distributed tablets to immune-compromised clients to ensure that they didn’t have to leave their homes. Other organizations, such as Hamilton-based Care Through Tech, collect donated phones for people who are homeless so that they can stay in touch with their health-care providers. A group of Toronto health-care institutions is doing the same.
“I think we need to stop looking at our phones and smart tech as a luxury. I say we have gotten to a place where they are a need,” Seymour says. “If you have a person who is homeless — who's struggling with substance abuse and trying to get healthy — that phone can facilitate recovery, because they can connect with their doctor.”
But equity in virtual care goes beyond access, suggests Allison Crawford, associate chief of virtual mental health at Toronto’s Centre for Addiction and Mental Health. “That is the gateway to the care, but it’s also about the experience: what kind of follow up you receive, what interventions you receive, whether you have privacy when you engage in care,” she says. “We have to look at equity through outcomes. We know that you can treat depression equally well on virtual care as in person, but do some people have a better outcome than others? And can we trace that back to equity? It’s not just about whether they saw the doctor in the first place.”
Before the pandemic, CAMH provided about 350 virtual appointments per month; the number has now risen to about 7,000 — half the usual number of in-person appointments. So Crawford and her colleagues worked to see whom they were missing and to identify potential barriers.
CAMH distributed a survey to learn more about patients’ virtual-care experience. It also prepared a digital-health equity framework to help health-care providers consider equity factors. The framework suggests, for example, that organizations provide digital-health-care training and hire people from vulnerable groups in leadership positions. Individual providers can take steps such as ensuring a patient has the proper technology, privacy, and, if necessary, a language interpreter.
“I think the ministry is paying a lot of attention to these issues and is committed to working on them,” says Crawford, who sits on an Ontario Health steering committee. “We just need to bring everyone together to hear the challenges and collectively try to come up with solutions — including talking with patients from vulnerable groups.”
A spokesperson for Ontario Health told TVO.org via email that “as virtual care has become mainstream, geographic, socioeconomic and other considerations remain of key importance when it comes to ensuring access to care for all Ontarians.” They noted that the Ontario Telemedicine Network operates video host sites that allow patients to connect with primary-care physicians, specialists, and health professionals across the province and that onsite telemedicine coordinators or nurses can provide additional support.
OTN, they added, is also working with municipalities to prioritize broadband-internet access and to use locations such as libraries for patients to receive virtual care, and partnering with Indigenous communities and Aboriginal Health Access Centres to improve access to virtual care.
“We need to keep doing what is working well, but don’t overlook the often overlooked and underrepresented," says Heesters. “The pandemic has exacerbated existing disparities related to the social determinants of health. Where we live, how we earn a living, our educational opportunities, financial circumstances affect our health outcomes in dramatic ways. We need to make certain that digital solutions are solutions for those we serve.”