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.”