PRAXES perspective on telemedicine and virtual care in Canada

PRAXES perspective on telemedicine and virtual care in Canada

Apr 13, 2020   |   Dr. John Ross MD FRCPC

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There is much in the news these days about telemedicine and virtual care. Although medical care via telephone, video and messaging has been around for many years, governments in many countries such as Canada, USA and the UK have been reluctant to fully fund it. These governments, and many patients and doctors, continue to believe that patient-doctor visits need to occur in person.

This COVID-19 pandemic has changed all of that ‘virtually’ overnight. With social distancing in place, doctors and patients urgently needed a new way to connect. Most provinces in Canada implemented a telemedicine fee code in March 2020, after years of procrastination and delays.

There are many companies that have entered this market in the past few years, most offering video conferencing apps. ZOOM has been much in the news as the go-to healthcare video platform. So what exactly is telemedicine? What can be done using telemedicine? Is video conferencing the same as telemedicine? Will access to telemedicine improve overall access to doctors in Canada? And ultimately, will this help people in Canada to live healthier lives?

PRAXES has been providing medical advice to companies and workers in remote locations for over 23 years. Most of our consultations have been via radio or satellite phone, as internet access has been, and continues to be, inconsistent. The key to providing good remote care is, like many things, all about preparation. We provide our remote clients with simple diagnostic tools, such as blood pressure cuff, thermometer, glucometer and oxygen saturation monitor, so that pretty much anyone can take a patient’s vital signs.  We provide a comprehensive medical kit that includes over-the-counter and prescription medications, so that we can treat simple, more complex and emergent medical issues.  We have a very simple process for connecting with us quickly, and have several physicians, English and French, scheduled each day.

1 – What is Telemedicine?

Telemedicine is the provision of medical advice and care when the patient and the medical provider are not in the same location. This can be as simple as a phone call, or as complex as robotic surgery, and everything in between.

2 – What can be done using Telemedicine?

PRAXES has been providing medical advice to companies and workers in remote locations for over 23 years. Most of our consultations have been via radio or satellite phone, as internet access has been, and continues to be, inconsistent. In our experience, the key to providing good remote care is, like many things, all about preparation. We provide our remote clients with simple diagnostic tools, such as blood pressure cuff, thermometer, glucometer and oxygen saturation monitor, so that pretty much anyone can take a patient’s vital signs. We provide a comprehensive medical kit that includes over-the-counter and prescription medications, so that we can treat simple, more complex and emergent medical issues. We have a very simple process for connecting with us quickly, and have several physicians, both English and French speaking, available each day. We provide additional medical training for workers that will be extremely remote.

Some of the medical issues that we have been able to assist in treating remotely are; diagnosing and managing appendicitis on a patient in the Southern ocean; treating infections of various kinds; treating kidney stones in a patient on an Atlantic crossing; managing fractures and traumas, including amputations; we have unfortunately had some patients who died, and our physicians have talked the onsite providers through all of the correct resuscitation procedures. The key in all cases was having the right medical equipment on board to be able to manage each of these events, and the personnel with the right training to (1) know how to call us quickly (2) know what was in their medical kit and (3) know how to use it.

3 – Is video conferencing the same as telemedicine?

Most telemedicine services provide a platform, just like a phone company, that connects a patient with a doctor, usually by video, or voice, or text message. What happens during the consultation is between the patient and the doctor, with the doctor creating written medical notes about the consultation. There is generally no ability for the patient to provide any vital signs, unless they happen to have their own basic medical equipment at home. Video can helpful for building trust and rapport, but is not that helpful in situations where the medical issue is not one that can be seen (e.g. belly pain). Most telemedicine providers do not voice record the conversations or take any responsibility for the care that is provided by the doctor to the patient. They rely on the existing system of licensing and review that is provided by the Colleges of Physicians and Surgeons and other provincial licensing bodies across Canada.

At PRAXES we take different approach. We are not a platform but provide a telemedicine service, and we are passionate about quality. We carefully recruit, interview, hire and train doctors who are typically referred by our current doctors. We have our own secure medical records software, and voice records of each consultation are saved as part of each medical record. All consultations are reviewed by our Quality Manager, and at least 5% are reviewed by our Medical Director. We provide feedback to our doctors on their care advice and use the call recordings for training and educational purposes. We provide feedback to clients on the care being provided at their remote worksites, and we are continually amazed at what fantastic care is being provided by workers with basic First Aid training! A skilled PRAXES physician can leverage the basic knowledge and skills of a caller to provide patient care equivalent to, and often faster than, the land-based public healthcare system.

After more than 23 years, here are some of the things we have learned about telemedicine:

• Not every doctor is comfortable providing medical care remotely. Doctors have different training, experience, confidence and risk tolerance in managing medical issues at a distance. This will likely mean that many doctors still want to see their patients in person. For land-based telemedicine, where patients can easily get in-person care at clinics or emergency departments, the threshold for deciding to treat a patient at home is much lower than it is for patients in very remote areas.

• Having vital signs information is very helpful. They are called ‘vital signs’ for a reason!  They provide objective information that can be used to rule out certain medical issues and distinguish ‘sick’ from ‘not sick’. Most patients at home do not have vital signs devices, and we encourage them to get these if they are going to use telemedicine services a lot. An inexpensive digital thermometer (very important during COVID-19!), digital blood pressure cuff, pulse oximeter and glucometer (if patient has diabetes) are really useful.  Some wearable devices are also able to provide some of this data.
• Older patients, and those with multiple health issues, can be difficult to manage using telemedicine. These patients ideally need to be proactively managed by a healthcare team that knows their full health history, including current medications. Over 30% of Canadians have diabetes or are pre-diabetic (diabetes.ca) and often have other medical conditions. Disconnected episodic care provided by multiple providers with access to limited information may not be a good fit for this population of patients.
• Primary Care Providers can be more efficient and effectively used through telemedicine (telephone-based medicine) and virtual care (adding video and other streaming devices.) The same goes for patients’ valuable time. While video consults may take the same amount of time as an office visit, patients can save considerable time in travel, reduce exposure to other sick people in a waiting room, and avoid missing work. Telephone calls and text messaging can be used quickly and effectively for follow-ups, test results etc. that frees up both doctor and patient time.
• We need to leverage the skills of other healthcare providers in the field, and triage cases so that they are managed by the person with the most appropriate skill set. Giving individual patients instant access to a doctor for every medical issue is not going to be sustainable, as we are already short of primary care doctors. Most of our clients have some level of medical provider on site to do the initial patient assessment, manage the medical kit, and contact the doctor. This person provides at least a first level of “triage” (which means ‘sorting’), takes the basic vital signs, and then contacts the doctor. We have captains on ships who, with just  two weeks of first aid training, provide excellent primary care for a crew of 35 – 40 workers, with the assistance of our doctors.

4 – Will access to telemedicine improve overall access to doctors in Canada? And ultimately, will this help people in Canada to live healthier lives?

We believe the model described above, that leverages the multiple skillsets of providers already working in our communities, should be the model that we extend through telemedicine. These suggestions will help to move us from reactive SICKNESS care to pro-active HEALTH care, and therefor help Canadians to live healthier lives. Here are some suggestions for how to do this:

• Add a nurse practitioner and doctor service onto the provincial “811” nurse triage services. We still have over 50,000 patients in Nova Scotia, and 4.8 million across Canada, who do not have a primary care provider.
• Provide more telemedicine support for continuing care workers (CCW), personal care workers (PCW), and other home care staff, so that they can treat their clients onsite as much as possible.
• Extend the telemedicine fee code to allow other practitioners, not just doctors, to have virtual consultations with patients.
• Increase the pro-active use of paramedics to do home visits, rather than just waiting for emergencies. Paramedics can assist in managing medical devices (e.g. catheters), providing wound care, and can also be given specific training to extend their competencies. Everywhere they go, they can have access to physician support telephonically or through video to assist in more complex patient care on-site.

In summary, telemedicine/virtual care has been long overdue as an integral part of our healthcare system, and it is here to stay.   If put to best use, it provides an opportunity to extend the reach and capacity of our scarce resource, doctors.   However, technology alone is not enough.   We must also invest in training for doctors and frontline healthcare providers to expand their capabilities to deliver better and more pro-active healthcare to patients in their homes.  If we can move from reactive disease care to more pro-active HEALTH care, we should improve the lives of all Canadians.

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