This May, a new “doctor in your pocket” app, Akira, became available in Canada. It’s the latest in a growing line of apps and websites that let patients connect with a doctor or nurse practitioner via text message or video chat. The health care providers can then diagnose diseases, write prescriptions and order lab tests virtually. Equinoxe launched a similar service called EQ Virtual in 2014 for the BC market, and has managed more than 40,000 visits since. Last week, it began offering EQ Virtual in Ontario as well. Meanwhile, Toronto-based Ask The Doctor offers advice from doctors and specialists via secure messages on its website.
In the US, the market is more established. HealthTap, American Well, Doctor on Demand and even Planned Parenthood are among many organizations that offer virtual doctor’s appointments. A parallel service is offered by apps like Heal, which offer house calls, allowing people to summon a doctor from their smartphone. The industry got a boost last year when UnitedHealthcare, the largest health insurer in America, decided to cover some virtual health care providers.
Canada already has telemedicine systems in place. BC pays for virtual consults by doctors. In Ontario, patients can call Telehealth, and those in certain areas can use Medvisit and MD Home Call to see a doctor, covered by OHIP, in their home. And of course, many primary care providers and specialists across the country also already correspond with their patients through the phone or by secure message. These new offerings differ in that they’re private services that connect patients directly to a doctor, most often a primary care provider they haven’t seen before. They often come at a cost, from $9.99 a month for Akira to $49 a visit with EQ Virtual.
“I think the health care system is going to totally integrate virtual health care just as part of the health care system — and it’s going to happen faster than people think,” says Edward Brown, chief executive officer of the Ontario Telemedicine Network (OTN). “Everybody’s got a smartphone, and you know you can use it to book an airplane ticket, to do your banking, to order your groceries. There’s only one thing you can’t do with it — see the doctor.”
Do doctor-on-call apps provide better care?
There’s a market for these apps in part because of two of our most stubborn problems in primary care: timely access and after-hours availability. Canada ranked second last in a recent Commonwealth Fund survey that looked at whether patients could get an appointment within a day, and last in another Commonwealth Fund report on access to after-hours and weekend care.
Telemedicine is generally accepted to be effective care for mental health issues and many physical problems as well, though that can be difficult to prove. One often-quoted stat is that Kaiser Permanente Northern California now does 50% of its patient appointments virtually — though that number also includes telephone calls. A recent Cochrane review of the science found that of 80 studies it reviewed, 20 were positive, 18 were “promising but incomplete”, and the rest offered limited or inconsistent data. An editorial concerning the review also pointed out the difficulty of studying such a fast-moving field. “It feels somewhat like sitting in a modern plane, reading about how zeppelins will transform the way we travel,” it reads.
But this new kind of telemedicine — where patients are connected with a different doctor every time — lacks continuity of care, which is one of the principles of good primary care. “We know that much of the value that primary care delivers comes in the context of a relationship in which that patient is known well, and the doc in the pocket apps really can’t provide that,” says Sarah Newbery, president of the Ontario College of Family Physicians. “Primary care providers are able to manage many problems over the phone or without needing to see that person face to face, but they have access to their complete records, they know the story, they know what they’ve presented with in the past. It’s often very difficult to get that record from a patient’s memory.”
Both Akira and EQ Virtual will forward information from their visits to the patient’s primary provider, with the patient’s consent. EQ Virtual also works with some family doctors, who use the platform as a way to see their own patients virtually and to offer more after-hours care. The company’s website points out that over 50% of the patients they see don’t have a family doctor, and a significant portion are from outside urban centres.
BC’s Health Minister Terry Lake expressed concern in 2014 that these services were essentially “virtual walk-in clinics” and that they might drive up costs. Telemedicine was originally covered in BC with the intent to serve remote communities, and are only covered in approved locations, such as video conferencing rooms in hospitals. In 2013, the fee rules were expanded to allow doctors more flexibility in where they provided their services.
Since then, as Ministry of Health spokesperson Stephen May told Healthy Debate, “companies [have been] looking at using virtual care throughout BC, in rural and urban settings. The Ministry believes technology can play a role in supporting access and the delivery of primary care services,” he continues. “However, it needs to be done in a manner consistent with simplifying the patient experience, having a single patient record, and a regular team of doctors and other health professionals providing care.”
The Ministry of Health in Ontario echoed those concerns. “Ideally, patients should receive care and coordination of care from their primary care provider or group,” says Joanne Woodward Fraser, senior communications advisor for the Ministry of Health and Long-Term Care. “Services that fragment care particularly at a primary care level are not being considered for coverage under OHIP, whatever the service delivery model.”
This lack of system support is one reason Ask The Doctor decided not to enter the market of offering live access to doctors. The Toronto-based company has doctors answer patient questions within one hour for a fee, and has answered more than 5 million questions worldwide. Patients can also ask doctors on the site for a second opinion, uploading documents such as CT scans or pathology reports along with their self-reported descriptions of their medical history.
The company was almost ready to get into the business of providing virtual and home doctors visits before deciding at the last minute to pull out. “We leased two Teslas, we had decals on them, we created our Android app, we had hired the physicians and we had 100 companies signed up,” says Michael Warner, chief medical officer of Ask The Doctor and a physician at Toronto’s Michael Garron Hospital.
But they decided not to move forward because they felt that the market had already become dominated by some major US players such as Doctor on Demand, and because e-consultations weren’t covered by many provinces. Instead, they’re sticking with their specialty, health advice without the ability to formally diagnose problems, write prescriptions or order tests. “We know that one-quarter to one-third of visits to doctors are for doctors to talk to patients about their medical problems, to explain something, review something,” Warner says. “Helping people understand what’s going on in their body is an important part of primary care.”
Should patients be paying for care?
Then there is the issue of patients paying for faster care and health advice in Canada. Businesses like Akira aren’t directly violating the Canada Health Act in charging patients, since getting medical advice by phone, email, text, or video visits isn’t covered by the Ontario Health Insurance Plan.
On its website’s Q&A, Akira compares it to going to the dentist, which is not covered by Canada’s publicly funded health care systems. But it’s not exactly the same, says Adrienne Silnicki, national coordinator for the Canadian Health Coalition. “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,” she says. Newbery adds that businesses like these could be dangerous if they’re pulling doctors out of care in the public system and into private companies.
The fact that virtual visits aren’t covered by OHIP also “makes the opportunity for [the public system] to be innovative or creative in many ways more challenging,” says Newbery. Capitated providers who are on salary or paid by the patient, rather than by the visit — do have more flexibility in how they deliver care, says Brown. But he agrees that he’d like to see this kind of care covered. Unsurprisingly, that’s a shift those companies would support as well. “We would be ecstatic if we woke up tomorrow and these services were covered,” says Daniel Martz, the CEO of Equinoxe LifeCare, the company that owns EQ Virtual.
The government-funded Ontario Telemedicine Network (OTN) already arranges thousands of covered telemedicine interactions, including many between doctors and specialists. It’s now focusing on connecting patients to primary care. “We want to set up a system where the patients can get same-day clinical advice,” says Brown, explaining patients would start by messaging a doctor — ideally a provider from their own practice who has access to their medical records — and then would escalate to a video call or an in-person visit if necessary. The OTN is in the preliminary stages of creating a pilot version of this system, which will be evaluated for its effectiveness.
In the end, services like Akira and Ask The Doctor show that “consumers are feeling a gap,” says Brown. “People are voting with their feet and using lots of other tools. Our challenge is to give them that level of service within the publicly funded health system.”
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How Hospitals are Ki#ing Us-and this “doctor” is at the Canadian helm.. Michael Warner
Veri nice dr
Wow. I am definitely going to share this with a few of my friends. Very cool information.
here …share something using critical thinking.. How Hospitals are Killing Us-and this “doctor” is at the Canadian helm.. Michael Warner
I have gotten a needle in my right upper arm approximately two weeks ago, the site still hurts and the movement is very limited. What should I do? And what can I do to help with the healing process.
Outcomes?? Efficacy?? No physical exam….No thanks!
What if I do not have a personal physician at this time? I cannot use the service?
Hi Regina, You can use these apps without having a physician. They will assign someone to you.
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/
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.
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.
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?
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.
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.
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
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!