The dramatic mainstream move to virtual care through video conferencing, hastened by the pandemic, is leaving some rural Canadians further behind.
The sudden shift during the pandemic was an effective tool when cases threatened to overwhelm hospitals. And while provinces like B.C. and Ontario have urged doctors to resume routine in-person care and have reinforced its importance, virtual care is moving into the mainstream of health-care delivery in Canada.
For rural Canadians, however, and especially those in remote and Indigenous communities, seeing a doctor in person comes with its own difficulties. And video conferencing often is not possible.
A Canada Health Infoway Digital Health Survey of 12,052 respondents from July to August 2021 showed that 79 per cent of recent virtual-care encounters were via telephone. Comparably, video calls were 17 per cent, messaging was 3 per cent and online COVID-19 assessment was just 1 per cent. When broken down for rural areas, Infoway’s 2021 Digital Health Survey showed phone consults are even higher.
“Everyone was using the phone during COVID-19 because it’s the easiest modality,” says Waldo Beausejour, an analyst at Infoway.
While virtual care has its critics and drawbacks, Beausejour notes that rural Canadians travel longer distances to seek care in person and therefore are in greater need of those services. Rural Canadians travelled, on average, 35.7 km to see their regular health-care provider/place of care and 31.9 km to the closest hospital with an emergency department; urban Canadians travelled between 12.6 and 18.3 km and between 8.5 and 12.8 km for the same services.
Although there is more research needed to determine if video conferencing is superior to virtual care by telephone, Kathy Rush, professor at the University of British Columbia (UBC) School of Nursing, says doctors may not be able to properly diagnose patients that need to be seen in-person, or at least over a video call.
However, she adds that video consultations require high-speed internet, which some rural communities do not have, noting that even having cell service can be a struggle for many.
“Sometimes, it’s so much easier for some patients to just pick up a phone and talk to their provider, and they can accomplish a lot if it’s about renewing a prescription or something simple … (but) there are great advantages to video conferencing (over telephone telehealth) … providers can diagnose their patients better; they can see them face-to-face and sense non-verbal cues.”
Leanne Currie, Professor at UBC School of Nursing and a nurse herself, says the issue previously had been about poorer patients not having access to technology; now in rural areas without high-speed internet, it’s everybody, including the health-care provider team.
“The fact that physicians don’t have high enough internet speed is a big problem. And it is largely because the initiatives for national broadband are relying on companies to provide broadband in remote and rural settings,” she says. “The infrastructure would have to come out of the goodness of (service providers’) hearts, but (most) are profit-driven companies and so there is no big motivation for them to build the infrastructure to support high-speed internet in those areas.”
“The people who can’t afford the infrastructure are already the furthest marginalized.”
“And we can’t do it if the infrastructure isn’t there and the people who can’t afford the infrastructure are already the furthest marginalized.”
Currie says that unless companies become motivated to build infrastructure for people who are in rural areas, the divide will continue in Canada.
Simon Hagens, Senior Director of Performance Analytics at Infoway, says that health equity has been a priority for organizations, the federal government and its provincial partners over the past couple of years.
For example, Health Canada has formed an Equity Task Team and produced a report on equitable access to inform the work of their partners in provinces and territories across Canada.
“What pops out for us is that virtual care absolutely has the opportunity to either address equity gaps or increase equity gaps,” he says. “Two years ago, there wasn’t a whole lot of talk about broadband. Now, there is a lot of talk about broadband because the data indicates that we have gaps and that people in rural communities don’t have the same level of access to things like video conferencing.”
Rush said that a lot of it has to do with income.
“Those with lower incomes, often in rural communities, don’t necessarily have the financial means to support buying some of the technology that could give them more access to the internet and that type of thing.”
Rush and her research assistant, Lindsay Burton, are conducting several studies in interior B.C. to determine how to provide better virtual care options and how the quality of care is impacting patients. One project is to help build digital literacy skills with older adults and Indigenous populations.
“We are trying to train them in using devices so they can actually build that skill set to be more confident when using video conferencing … but there are still a lot of other things (such as high-speed internet, third party, social environment) that need to be in place for them to be able to use that technology and benefit,” says Rush.
Burton also noted that even when the infrastructure, technology and skills are in place, issues occur. “You get set up and you take extra time to do that. And then the quality of the video conference is so bad that you end up having to default back to telephone anyway,” she says.
B.C. is currently facing a shortage of family doctors, and there have been other doctor shortages seen across Canada, especially in rural areas. Burton said that this is adding to issues around access to providers and a reason why many providers are resorting to telephone when patients do not have broadband.
“It is helping a lot of people, but at the same time, for people who don’t have access to those tools and that infrastructure, it is widening their gap and their access to care.”