Doctor on demand apps let you skip the waiting room. But experts urge caution


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  1. Will Falk

    This is an excellent article which summarizes the state of progress on virtual care. Clearly huge pent up demand

    I would go even further on the danger of privatization. If Ministries don’t move to open up these services we are going to allow private care come in to Canada thru virtual care. Canadians want modern access to their providers. Because EVERYONE values this, those who have the means will pay for it. If we inadvertently allow a second tier to open then shame on us

    The authors are a bit unfortunate in their timing as the BC data from the 2015 study commissioned by BC were just released quietly earlier this week. https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/3105-virtual-visits-in-british-columbia-2015-patient-survey-and-physician-interview-study They show 91% of consumers found virtual visits helpful and that 57% of those visits avoided a physical visit. Lots of good data around why consumers want virtual. No real surprises. People find videoconferencing a viable alternative to meeting face to face. Wow! Some good info that rebuts the continuity of care concern that Has been being elevated to the status of an “urban myth”. The data show that virtual care often avoids walk in visits. It doesn’t replicate walk ins unless it is misconstructed

    • Sarah Newbery

      Great to see the BC study information – thank you for sharing that!
      I think that part of the issue of continuity in the BC study worth noting is that approx. 45% of people felt that the provider had access to their information (test results,etc); 55% felt that there was access to their history. That forms part of “informational” continuity which has some value. While the BC info is great from a patient experience standpoint, what is not clear from the info presented is any health outcome information and it would be really interesting to know that as well.
      The “Towards Optimized Practice” group in Alberta has recently put together this very helpful summary of the information on continuity (112 articles) that looks at the value of continuity from the standpoints of: utilization, health outcome, mortality, adherence to treatment recommendations, care quality, health savings and preventive care. At a population level then, the importance of individual continuity with a primary care provider appears to matter. Here is the link with a great infographic summary: http://www.topalbertadoctors.org/file/top–evidence-summary–value-of-continuity.pdf.

      Thanks again Health Debate for stimulating discussion!

  2. James Bateman

    Services like MedChart ( https://www.medchart.ca/ ) can help with the continuity of care issues related to virtual care. Any patients in BC, Alberta, or Ontario can use it to take ownership of all their clinical notes from any doctor – including virtual ones – and make sure they are shared with all of their other physicians. It works with any physician as long as they have an internet connection or fax machine (so sad).

    Physicians charge patients for this data so there is a cost since requesting your medical records is not covered under provincial plans. But I guess this speaks to the need for the Canadian government to cover these sorts of 2-teir fees so patients can have access to their data without fees. MedChart is a step in the right direction to empower patients today to proactively overcome these continuity of care issues by simplifying how they get and use their data as partners in care.

  3. Cathy Faulds

    Where there is a demand, service will follow. The use of virtual “visits” for family doctors will reduce ER visits and demand on family practice offices. I think that having the ability to check on the need for a visit or have a question answered is a forward approach to reduction in physician and healthcare system funding. It must however be mirrored with continuity to a provider such as a family physician or it risks fragmentation of care. Fragmentation has been shown to increase visits back to family physicians, increase prescribing, increase poly-pharmacy, duplicate testing and delay diagnosis. These are all responsible for increased system costs. Strong patient-physician relationships have been shown to promote higher health care outcomes at reduced cost.
    This concept, while patient friendly and steeped in convenience, should be offered to family physicians with remuneration. It would allow timely access to care without loss of continuity and system fragmentation. It would be a win for patients, physicians and the health care system.

  4. Dustin Walper

    Co-Founder of Akira here. I should note that the authors of this article spoke to me at length, but did not quote anything I said that was directly relevant to the issues raised here. So I suppose I’ll address them here.

    First, Akira offers patients complete access BY DEFAULT to their accumulated record through the Akira app, including SOAP notes and conversation history. This is part of our commitment to democratizing access to health information for patients and is modelled after the OpenNotes initiative (http://www.opennotes.org/). When Sarah Newbury says “It’s often very difficult to get that record from a patient’s memory”, that’s because patients historically have not been permitted to access their records without begging and cajoling (and possibly paying a fee for printing and administrative time).

    Second, we always want to provide a note to the family physician if the patient consents and if they have a family physician. We do this by fax currently, but we’re looking at ways to open up Akira so family physicians can use it in their practices as well. Continuity of care is important to us and to the doctors and nurse practitioners we work with and is literally discussed every single day at the leadership level.

    The authors of this article unfortunately did not interview any actual patients. Patients would tell you that they are, by and large, incredibly frustrated by access issues and the c. The Commonwealth Fund studies cited here are telling – we have a health system that is more expensive than most and that underperforms on almost every metric. The UK, the top-performing system studied, shares Canada’s commitment to health equality, but organizes care differently and has been offering these kinds of services both privately and through the NHS for several years. Take a look at Babylon Health, a private company – the NHS actually champions their partnership as a positive thing for patients.

    Adrienne Silnicki states that “The health act covers people being able to see their physician. So if you’re speaking to a physician, even if you’re using new means… I think ethically there’s an issue there.” Unfortunately, Adrienne is incorrect – the Canada Health act is a short read (I’ve read it), and it does not say this at all. It says that, as a condition of receiving federal money for healthcare purposes, provinces must provide “medically necessary services” without user fees and then leaves the definition of that up to the provinces. What’s on the schedule of benefits in any province is covered, what’s off is not and can be charged for privately. The Ministry has very deliberately chosen not to cover telemedicine up until this point for budgetary reasons. This is not some loophole we’ve found that’s waiting to be closed.

    In Ontario, telemedicine is a clearly uninsured service. Heck, even the OTN’s website says that telemedicine is uninsured. So it’s quite a leap to claim that this is somehow an ethical issue – the true ethical issue here is that patients are being denied timely access to care. We’d have no issue at all if OHIP chose to cover this service in the future.

    But all that aside, this article misses the most important point of all: the (near) future of healthcare is tech-enabled. It involves integrating data from multiple sources, including connected devices, electronic health records, genomics/epigenomics/microbiomics, lab results, imaging, and more. It requires machine learning and artificial intelligence to make sense of this data and provide insight and predictions that can be acted upon by humans. And it is longitudinal, not episodic, with a focus at its core on preventing disease.

    This kind of transformation will not come from bolting software onto existing practice methods. It will involve inventing creative new ways of delivering care, and it will take physicians, nurses, engineers, designers, and data scientists working side-by-side to accomplish. We have to decide whether we, as a country, want to be at the forefront of this new kind of healthcare by supporting local efforts or if we want to let other countries do it for us.

    At Akira, our doctors literally sit next to our software developers and designers to provide continuous feedback into how to make care better. Ideas from doctors often make it into our software within days or weeks. Our Chief Medical Officer routinely reviews cases for quality. We collect patient feedback after every single consult and use it to pinpoint areas for improvement. Our doctors are working on creating new practice standards based on their experiences. And we are at the beginning stages of integrating machine learning techniques to help our practitioners deliver the highest possible quality of care in a way that is personalized to the patient.

    We’re really excited about the future, and I hope that attitudes start to shift in some of the more traditional healthcare organizations. Change can be scary, but it’s necessary.

    • Teresa

      Thank you for your comment. I used Akira a few weeks ago and I was surprised to learn that they no longer employ physicians on their team. To use their services, it is $360.00 per year! How is their service better than something like GOeVisit, which employs physicians and is covered by OHIP?

  5. Darren Larsen

    This is a really interesting and informative article and clearly outlines some of the business and technical issues which have become barriers to widespread adoption of virtual care tools. In my mind the real barriers are not technology or funding models, they are cultural. In the fee for service world it is easy to understand why a face-to-face visit is seen as the best form of care, but where many of us have switched payment models to capitation or salary and are free to see patients in the manner that bests suits the circumstance, our behaviour has largely not adapted. Virtual care is seen as an afterthought or a second-class visit. This needs to change.

    In large health systems in the US (like Kaiser as quoted above) an edict from above may serve to move the culture forward. A mission of having 50% of visits delivered virtually, aligned with corporate vision and values is helpful. It is both a carrot and a stick. This is much more difficult in the independent practice environment of Canada. In my mind, integration of these technology products into the existing clinical setting is key. I need virtual care tools to be part of my existing practice . They need to be integrated into my general care workflow. If Akira or its competitors could be part of my practice rather than outside of it, I would feel great about using it myself and/or endorsing the doctors hired within it as extensions of my team. I think this is the secret sauce. Virtual care tools should be complementary not competitive. They should enhance my patient experience with my practice not force them to go outside of it. They should be built on relationships of professional trust of the clinicians working within them that can be extended to my patients.

    Of course, this perspective is purely clinical. We are then left with the elephant in the room: “who is going to pay the tech vendor?”. As video conferencing is an uninsured service in Ontario it is possible that patients could be billed for access as any third party service. This runs the risk of being inequitable and disenfranchising some of the patients who would most benefit (ie: the single mother with two jobs who is struggling financially and cannot easily come to the office). Physicians could pay and absorb this service into their total overhead cost, but there is resistance in some jurisdictions as revenue streams have been cut back and many doctors have yet to think about the value added to their practices by virtual care (ie: fewer long in-patient visits may leave room to allow a roster to grow slightly — even two new rostered patients in a practice may make up the cost). The service costs themselves could be funded by government as a grant or adoption strategy as happened with EMRs and in the early days of OTN. And perhaps even a combination of the above could be contemplated.

    The bottom line is, we need these tools in our offices. We must think creatively about how to work with vendors to ensure scale and spread. And we have to begin a culture shift toward seeing virtual visits as equal or sometimes better than the current standard in-office care. Building a few beacon practice to get this work going is where we could begin.

  6. Hari Kumar

    The healthcare mobile integration is still on a budding stage and the innovation is going at a fast pace. Global giants are investing money into the health care field considering the richness the health care can offer them back. There are a lot of apps which are already popular, like the Continuous Care app which offer remote patient consultancy features. These kinds of mobile applications give the patients and doctors an advantage of convenience. Continuous Care also allows the patients to submit their medical reports and send it to the consulting doctor. The rising pace of users is a strong indication that people have started accepting mobile health care. To know the details of the medical app, check out the continuous care website: http://www.continuouscare.io/

  7. Regina O'Leary

    What if I do not have a personal physician at this time? I cannot use the service?

    • Vanessa Milne

      Hi Regina, You can use these apps without having a physician. They will assign someone to you.

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