I will never forget Emily, a 23-year-old patient in my family practice. We would talk about issues like immunizations, cancer screening and contraception. Then came one tragic summer morning. A car collided with Emily’s bike. She survived the accident but needed surgery for a broken leg.
Several weeks later, we were working on her recovery. Emily had a tough time moving so we met virtually. “I feel tired, but I’m sure it’s the pain pills,” she said one day, feeling exhausted and a little short of breath within minutes of starting her exercises.
The virtual visit meant that I could not examine all of Emily’s vital signs or her heart and lungs. Yet, I could see her on my screen and I remembered how she looked when healthy. She showed me the high heart rate on her smart watch. She sounded anxious and her face was flushed. My intuition, formed over years of visits with Emily, told me something was wrong. I told her I was worried and that she should go to the hospital.
Emily was reluctant but trusted me. The doctor at the hospital diagnosed her with a pulmonary embolism, a blood clot in her lungs that may have ended her life were it not for timely treatment. Virtual care allowed Emily the visit but continuity of care saved her life.
Virtual care promises access to people seeking care, wherever they need it. For Emily, the combination of access and continuity made the difference. Continuity of care involves seeing the same person or team for care over time. In caring for our health, continuity of care brings more than comfort and confidence – it adds quality to care and years to life. At a time when many are seeking care virtually, continuity is as important as ever.
Many like Emily benefit from continuity of care but more than a million Ontarians do not have a family doctor or primary care professional. Across Canada, offerings such as the Ontario Virtual Care Clinic continue to scale rapidly to temporarily meet this need. Like regular walk-in clinics, they form an important safety net and help many people access care. Similar to regular walk-in clinics, however, virtual walk-in clinics often lack any form of continuity with the rest of the healthcare system. For Emily, it would have meant seeing a stranger, with no understanding of her story, health or values and no way to connect that care to her family doctor.
Virtual walk-in clinics have a place but they must be in a broader system that promotes continuity of care.
Unlike in-person care, virtual care has the benefit of being accessible regardless of place, meaning Emily and I could meet despite her broken leg. In my practice, the virtual option allows both access and continuity to many who find it difficult to meet in-person or during office hours – working parents, young families, older adults whose caregivers join the visit. Virtual care lets Emily and others like her receive the right care, for the right problem, at the right time, by the right person. By removing barriers around transportation, virtual care can promote continuity with a dedicated health professional.
Although continuity with one clinician has benefits, it is not always realistic. No matter how dedicated, one family doctor cannot be available at all times and in all contexts. Continuity from a dedicated team is more practical. For a team, virtual care can bring the connectedness that health professionals need to thoughtfully collaborate.
Imagine if we all had a team of experts to manage and coordinate our care who may not always be co-located but could nonetheless work together through technology. I could connect with Emily’s surgeon, physiotherapist and pharmacist, track her progress, dose her pain medications and work with them on her health. Through technology, we could collaborate as if we were in the same office. By removing the location barrier, virtual care can promote continuity from a dedicated interdisciplinary team.
Sometimes, people need urgent care from clinicians outside of their dedicated team. When this need arises, the onus should not be on patients or caregivers to repeat traumatic stories or to compile tomes of health information for the visit. If Emily needs to see a doctor from another office, we must create a system in which this new doctor can see Emily’s medical records, recent lab results and general goals of care. After the visit, we must make it easy for clinicians to connect that episode of care to the person’s dedicated care team. As a minimal standard, virtual care must promote continuity of data.
Discontinuous care should not be the only option for people without a family doctor or primary care professional. People without some form of continuity often receive fragmented care by multiple professionals and no longitudinal health guidance.
In the Hamilton Spectator’s Code Red series, investigators found that the neighbourhoods with the fewest residents connected to a family doctor were also the ones with the most emergency visits for mental health crisis, highest rates of poverty and the worst maternal health outcomes. Virtual care’s adoption curve risks widening this chasm.
Many Canadians also will face the digital determinants of health, lacking internet access, proficiency with technology, a safe space to have personal conversations and a caregiver to help with their visit, not to mention other structural barriers.
For many people, there is a difference in the care they might receive while in a shared living room, away from the privacy and safety of their doctor’s office. Emily, for example, lives with her parents and is more comfortable discussing mental health or sensitive issues in-person or from the park. Accessible virtual care does not replace the need for continuous virtual and in-person primary care. Despite virtual care’s rapid adoption, we cannot leave any Canadian behind from high-quality primary care.
The evidence is clear: healthy primary care policy creates healthy communities. For people like Emily, virtual visits with her family doctor’s office promote access and continuity. Every Canadian deserves the kind and careful care made possible by continuity in all its forms. Especially for the millions of Canadians without a family doctor, our provincial ministries of health must ensure a system in which every Canadian has virtual and in-person care grounded in a continuous medical home.
With the promise of technology, it is beyond time that we cement continuity as a core value for the care of all Canadians, in all contexts, with all clinicians.
The comments section is closed.
“Continuity of care” is a crock — even if a patient is rostered for years with a family doctor within a team, that doesn’t actually mean any worker in that team will even keep the appointment made hours, days, or weeks before. So the EDs fill up and the patients are blamed as “bse”, “not sick enough”, being “mental”, having gas when its actually a stoke or heart attack, “merely constipated” (that was my 20+ son, who actually needed an emergency gallbladder removal within 36 hours, like *all* of his aunts in their 30s) or whatever label is derogatorily applied. While this author sounds great, too many of her colleagues give the impression that “continuity of care” mainly means “continuity of billings” or “exclusive rights to control the health care services” a patient is qualified for, and while a 20-something female is sympathetic, so qualifed for true care, a 50+ female is likely to have her concerns minimized to the point of barely-disguised, contemptuous dismissals – unless the issue is life-threatening and so allows the professional team to stroke their own egos by acting as heroes. And yet, the medical industry staff wonder why trust in the profession is declining, or why so many of us avoid health care businesses unless we’re in extremis.
The author is correct when he writes, “Virtual care’s adoption curve risks widening this chasm.” I’ve now had 3 virtual visits, and while the last one was fine, the first two with a family doctor who was supposed to treat my chronic conditions (but didn’t) were clearly designed for her benefit – not mine. Yes, I fired the princess, as I cannot trust a credentialled physician who ignores blood work results that even this layman could read and understand. (Nor was the bloodwork fiasco her first strike; it was just the final straw.)
Thank you, Dr. Nowak. I wish all doctors were as caring as you.
Marg Wood
In Ontario, and I suspect other provinces, we already have a call centre for health issues and a few Doctors On Call. Why not adapt these exiting services to provide virtual visits. R.N.s and N.P.s can do a better initial screening, resulting in less callers being sent off to the E.R. Also, if you already have a doctor, they should all be accessing the same technology, and be able to connect to other doctors, and hold joint consultations, etc. to ensure safety re confidentiality. Seamless care will save money and lives.
Given the ubiquity of the technology to make virtual care as effective as it is and will be increasingly, that Emily has “medical records” (plural) is irresponsible and that HER record(s) are not available to her is shameful.
Dr. Nowak,
Excellent article.
Allan
Next comes the Hologram…
and increased opportunities for continuity. However, if the OHIP SOB fails to value continuity, it will at best be accessible to only those whose physicians thrive on passion alone.
An insightful and enlightening article Dr. Nowak!
Well done Dominik
My issue with Virtual is when it comes to duplication of services and assessing virtually when better visualization or assessment is required. Virtual is convenient and my other concern is, like anything it can be abused. Guidelines need to be in place fit that. Well done and keep it up!! Mike Kates
Great article making the clear distinction between telemedicine, a onetime event, and Virtual Care being a connected, patient centred approach that facilitates care continuity to patients, whether local to the physician or in remote communities. This is aligned with our vision at http://www.healthespresso.com where a connected, patient centred platform connects not only the primary physician, but the entire circle of care to avoid service duplication, fill care gaps for better health outcomes.