Provider-Led Virtual Care in Ambulatory Care

Last Updated: August 28, 2020

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Purpose

This note provides a summary of scientific evidence and Canadian/international experiences on clinician-led virtual care services used to replace in-person care in hospital-based ambulatory care settings.

*The full version of the Briefing Note including the Appendix can be accessed in the PDF file at the top of the page*

Key Findings

Analysis for Ontario

Supporting Evidence

This section summarizes scientific evidence and lessons learned from international and Canadian
experiences on clinician-led virtual care services used to replace in-person care in hospital-based
ambulatory care settings. Findings are organized by: the type of technology used, the type of services
offered, the type of patients consulted; and effectiveness and impact of virtual care.

This Briefing Note was completed by the Research, Analysis, and Evaluation Branch (Ministry of Health)
based on information provided by members of the COVID-19 Evidence Synthesis Network. Please refer to the Methods section for further information.

Scientific Evidence

  • Information on virtual care technologies was identified from scientific evidence sources pertaining to the topics below:
    • The type of services offered: There are different services offered within synchronous and asynchronous virtual care technologies, and overall videoconferencing was identified as the most commonly used virtual care technology, followed by telephone calls, telemonitoring, teleconsultation, and store-and-forward (e.g., photos).
    • The type of patients consulted: Most virtual care technology is offered to patients seeking: endocrinology care (e.g., diabetes care), mental health and additions care, outpatient care, obstetrics and gynaecology care, and inpatient care.
    • Effectiveness and Impact: Virtual care technologies are effective in improving patient and provider experiences, and are cost-effective. In particular:
      • Patient experience and equity: Patient experiences with virtual care technology are overall positive compared to in-person care. Common themes of patient satisfaction when using virtual care include reduced travel (i.e., fewer trips required), increased quality of care, and reduced time travelling.
      • Provider experience: Provider experiences with virtual care technology is overall positive compared to in-person care. A common theme pertaining to provider satisfaction when using virtual care includes reducing physician related medication errors.
      • Cost-effectiveness: Virtual care technologies are cost-effective in comparison to in-person care, with cost savings being reported from reduced travel and accommodation expenses.

International Scan

  • In the US, there are eight large hospital networks (i.e., Cleveland Clinic, Dartmouth Hitchcock Health System, Johns Hopkins, Kaiser Permanente, Massachusetts General Hospital, Mayo Clinic, NYC Health + Hospitals, and Providence Health and Services) which had extensive virtual care services in place prior to the pandemic. However, four of these hospital networks had to increase their capacity to provide virtual services as a result of the COVID-19 pandemic.
    • The type of technology used: Specific virtual care programs used to provide virtual services across the eight hospital networks include: Cleveland Clinic Express Care Online, Doximity Dialer, Facetime, Google Duo, Mayo Clinic Express Care Online, Microsoft Teams, MyChart, Virtual ExpressCare, and VirtualVisit SBR Health App.
    • The type of services offered: At Kaiser Permanente, the majority of virtual services are telephone-based, although other options, including email and chat services as well as synchronous video visits, are available. The Mayo Clinic, NYC Health + Hospitals, and Providence Heather Services operate similarly, while Dartmouth-Hitchcock Health System and Johns Hopkins rely more heavily on video consultations. During the pandemic, NYC Health + Hospitals transitioned visits to be telephone-based with all ancillary team members (e.g., chronic disease nurses, nutritionists, social workers) and some administrative roles.
    • The type of patients consulted: Virtual services are offered to patients seeking:
      • Initial COVID-19 consultations (Kaiser Permanente);
      • Cancer screening (e.g., colorectal cancer) (Kaiser Permanente);
      • Management of and monitoring of various chronic conditions (Kaiser Permanente; Providence Health and Services; Johns Hopkins; Cleveland Clinic);
      • Management and monitoring of various complex conditions (Kaiser Permanente; Mayo Clinic; Providence Health and Services; Johns Hopkins; Cleveland Clinic);
      • Virtual cardiac rehabilitation (Kaiser Permanente);
      • Virtual dermatology (Providence Health and Services);
      • Virtual oncology services (Providence Health and Services);
      • Virtual pediatric care (Dartmouth-Hitchcock Health System);
      • Virtual psychiatry, mental health and behavioural services (Providence Health and Services);
      • Virtual triaging for local emergency rooms (Dartmouth-Hitchcock Health System); and
      • Virtual medical rounds (Massachusetts General Hospital).
  • Local Health Districts (e.g., Adelaide, Kingswood, New England, New South Wales, Sydney) in Australia reported on virtual care technology in general (i.e., not specifically in the context of the COVID-19 pandemic):
    • The type of services offered: Synchronous videoconferencing is the most commonly used virtual care technology, followed by asynchronous store-and-forward technology (e.g., photos).
    • The type of patients consulted: Most virtual care technology is offered to patients seeking: endocrinology care (e.g., diabetes care), mental health and additions care, outpatient care, cancer care, chronic spinal care, remote and rural care, aging and geriatrics care, cardiac care, and inpatient care.
    • Effectiveness and Impact: Australia reports virtual care technologies being effective in improving patient and provider experiences, and are cost-effective. In particular:
      • Patient experience and equity: Common themes of patient satisfaction when using virtual care include increased access and equity, reduced travel, increased quality of care, and increased access to timely supports and care.
      • Provider experience: Common themes pertaining to provider satisfaction when using virtual care include reduced travel time, increased patient consultations, increased geographic coverage, reduced burden on health care system, increased quality of care, and increased time of service.
      • Cost-effectiveness: All Local Health Districts in Australia report that telehealth models are cost-effective.

Canadian Scan

  • At the provincial level, 10 hospital networks across four provinces (i.e., British Columbia, Alberta, Ontario, and Quebec) are using a range of platforms to conduct virtual care services.
    • The type of technology used: Virtual care technologies include Microsoft Teams, Ontario Telemedicine Network, Vivify Pathways, Zoom for Healthcare, REACTS, Pexip, Webex, Lumeca, Doxy.me, Memora Health, Accuro EMR – QHR Technologies, Med Access EMR – Telus, Maple, Econsult, eDOCSNL which are used for synchronous video and audio consultations, and asynshronous store-and-forward.
    • The type of patients consulted: Most virtual care technology is offered to patients seeking care related to: mental health, sexual health, obstetrics and gynecology, optometry, genetics, oncology, surgery, nephrology, respirology, neurosurgery, rehabilitation services, group patient education, and neurology. In response to the pandemic, some Canadian hospital networks have expanded their virtual offerings and are providing a range of ambulatory services using synchronous video and audio including:
      • Virtual consultations for cancer patients that have tested positive for COVID-19 (University Health Network [UHN] – Princess Margaret Cancer Centre);
      • Virtual cardiac rehabilitation program (Vancouver Hospital and Health Science Centre);
      • Virtual management and monitoring for heart failure (UHN);
      • Virtual oncology services (UHN);
      • Virtual peri-operative care management and monitoring (UHN);
      • Virtual post-operative care for cardiac and vascular surgery (Hamilton Health Sciences);
      • Telepsychiatry (UHN; Centre hospitalier de l’Universite de Montreal);
      • Drug addictions services (Centre hospitalier de l’Universite de Montreal);
      • Virtual prenatal checkups (London Health Sciences Centre; Centre hospitalier de l’Universite de Montreal);
      • Virtual triage for pediatric urgent and emergency care (London Health Sciences Centre); and
      • Telephone line for triage with nursing staff (Centre hospitalier de l’Universite de Montreal).
    • Effectiveness and Impact: Canadian provinces and territories report virtual care technologies being effective in improving patient experiences. In particular:
      • Patient experience: At the pan-Canadian level, Canada Health Infoway released a report (July 20, 2020) that examines the experiences of patients shifting to virtual services. It was generally found that patients are less satisfied with virtual visits than in-person visits and tend to be more satisfied with telephone consultations than synchronous video or asynchronous messaging. Ontario, Manitoba, Saskatchewan, Yukon, Prince Edward Island, Newfoundland and Labrador, Northwest Territories, and Nunavut report the importance of ensuring the privacy and security of personal health information; data management and recording of personal health information virtual visits; ensuring patient centered good quality care; and equitable and fair access to marginalized patient populations when using virtual care technology.
    • Cost effectiveness: Ontario, Manitoba, Saskatchewan, Yukon, Prince Edward Island, Newfoundland and Labrador, Northwest Territories, and Nunavut note the importance of ensuring a fair and correct payment model when using virtual care.

Ontario Scan

  • Five health systems in Ontario were identified that are using virtual care services:
    • Hamilton Health Sciences
      • Hamilton Health Sciences has implemented virtual care services that enable patient-clinician communication through phone calls and/or home-video visits (eVisits) during the COVID-19 pandemic.
      • As of May 6, 2020, there are three approved modalities for virtual care visits: 1) Ontario Telemedicine Network; 2) Zoom for Healthcare; and 3) telephone.
    • UHN
      • UHN has implemented the use of virtual care in the form of phone visits and video visits using conferencing tools provided by Ontario Telemedicine Network and Microsoft Teams.
      • Princess Margaret Cancer Centre started a Nurse-Led Virtual Care Clinic, which aims to support cancer patients that have tested positive for COVID-19.
      • On June 25, 2019, UHN partnered with Vivify Health to offer Vivify Pathways Go, a peri-operative care management and engagement strategy that allows for the remote monitoring of patients.
      • In 2016, UHN launched Medly, a digital tool that aims to provide support to heart failure patients. This service is designed for patients to monitor their own heart health, obtain personalized feedback messages, and communicate remotely with their care team as needed.
    • Humber Hospital
      • In March 2020, Humber River Hospital implemented Virtual Video Visits for clinicians to interact and connect with patients from home. This virtual-care service is conducted through audio (telephone) or video (Microsoft Teams) technologies.
    • London Health Sciences Centre
      • Non-urgent or outpatient appointments have largely been re-scheduled and are now taking place through phone and virtual consultations.
      • On May 19, 2020, the London Health Sciences Centre announced virtual prenatal check-ups with obstetricians for expectant patients.
      • On May 11, 2020, the London Health Science’s Children Hospital launched an urgent and emergency care virtual clinic. Under the clinic, families of children with complex needs can connect with a physician to evaluate their child’s condition and determine next steps.
    • Ottawa Hospital System
      • On April 27, 2020, the Ottawa Hospital launched Epic-Zoom virtual platform for health care providers to connect with patients through video for non-urgent appointments and outpatient programming.
      • As of July 2019, the Ottawa Hospital provides all patients receiving care a partner locations access to MyChart free of charge.

Methods

The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision makers as the pandemic continues. The following members of the Network provided evidence synthesis products that were used to develop this Evidence Synthesis Briefing Note:

  • McMaster Health Forum. COVID-19 Rapid Evidence Profile #16 – What clinician-led virtual-care services can be used to replace in-person care in hospital-based ambulatory care settings? July 31, 2020.
  • Canadian Agency for Drugs and Technologies in Health (CADTH). Informal Jurisdictional Scan on
    Virtual Care Visits. August 28, 2020.
  • Evidence Synthesis Unit. 857. Rapid Response on Provider-Led Virtual Care in Ambulatory Care.
    August 20, 2020.