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The following is feedback from @Colin, and healthcare IT specialist and consultant.

General comments

The Guide is a great starting point for physician offices who may not be up-to-speed on the latest trends in virtual care. I think they will appreciate the perspectives that are contained in the Guide. There is lots for them to consider and think about.

Introduction and background information

Question: Did the Introduction, Values and Guiding Principles in the Guide document provide sufficient context for the Guidelines? Is there any information that was not covered that would be helpful?

Response:

• In the Possible Audiences section I would suggest adding:
  • Physician Assistants
  • executive directors at physician practices
  • members of patient and family advisory councils (PFACs)

Structure and organization

Question: Do you have any feedback on the structure and organization of the Guidelines? From your perspective would you organize them differently? How and why?

Response:

• I think the overall structure of the Guide is great. It flows nicely and is logical.
• Suggestion – the privacy guidelines are in the technology section, but privacy is about much more than technology and a lot of the suggestions/functional needs/clarifying questions are more related to the physical environment than about the technology being used. I would create a section 1.4 that was specific about privacy and include it in the portion about the person receiving care.

Relevance of information

Question: Did any of the information in the Guidelines feel non-applicable, incorrect or insufficient in the context of virtual care?

Response: 

• Overall I think the information provided in the Guidelines is correct and applicable.

Content to consider adding

Question: Is there any information you feel is missing from the Guidelines?

Response:

I believe the Guidelines is missing a section that empathizes with the situation some practitioners find themselves in.

Although not intentional (I hope it’s not intentional) but the sections are all geared towards making the experience of virtual care better for patients…which is absolutely important. But it’s also important that practitioners have a good experience so that they will continue to invest/use virtual care.

This Guide need a section that has suggestions and information for the practitioner.

For example, much like individuals receiving care, there should be a section that talks about how practitioners need the physical support for using virtual care. Similarly practitioners may not have optimized their offices to provide virtual care. Here is what I mean:

• Most doctor’s offices have exam room but shared office space for the multiple doctors in the practice
• That shared office is not usually optimized for virtual care – ie: you can’t lock the door so someone may walk in, it’s also got a telephone which may or may not have a DND feature so you may get a lot of noise during a virtual care session. The office may also have other patient records and private information that shouldn’t be broadcast in a session
• Tying up an exam room for virtual care is not good either – as that will REDUCE the overall capacity of the practice to see patients

There is also the issue of time. When and how should practitioners offer virtual care. Should they dedicate a day to virtual and others to in-person rather than mix the two in the same day? That is what best-practice that seems to be emerging.

Some other questions that the guidelines can help answer for practitioners:

• How can they update their consent forms to acknowledge they now offer virtual care – it’s not likely that their old intake forms have provisions for this modality, so how should they do this?
• Can they do virtual visits from their home?

Content to consider expanding

Question: Is there any information you feel we should expand upon?

Response:

Privacy

• In the privacy section there should be information about the use of non compliant virtual care options. For example Face Time. Face-Time is not PHIPA compliant (nor is Google Hangouts), BUT it can be used to deliver care if the patient consents. Obviously it would be better if another option that was secure/complaint was used, but in some cases that’s not possible. Given the scarcity of doctors and the difficulty in scheduling appointments, it would be far better to have the virtual care session than to defer it to another time when the “right platform” can be used. Both doctors and patients need to be educated on the fact that PHIPA does not ban the use of certain tools, it just provides a framework on what the rights people have to their health information and patients do have the right to make exceptions on privacy for themselves
• I would add a statement in the Privacy-Practices section about practitioners updating their patient intake forms to reflect the modalities of care/communication that they now offer – text, video, secure communication apps, patient portals, etc. This will ensure NEW patients have the right information. There also needs to be a practice that talks about going back to existing patients to tell them about the changes and getting them to consent again to those modalities of care. This is not something that many do.

Technology

• One of the big things that is missing from this section is AUTHENTICATION of the patient and the physician. How does the physician know that the person they are talking to is actually the patient that they are supposed to be seeing? How is the patient know the physician they are talking to the right one? Anybody can change their name on a video meeting app. Some dedicated Telemedicine apps solve this problem, but they need to be integrated with patient portals…which not every physician practice will have. One easy work-around is for patients to compare the person on the screen to any identification that they provided during intake (ie: driver’s license, health card, etc). Another is to use a special verbal password (like what credit card call centers use). For the practice, having photos and bios of their physicians on their website will allow patients to visually verify that the person they are speaking with is actually the doctors they wanted to see. This is key to establishing TRUST.

Other

• One of the most frustrating things for a patient is finding out 1 minute into a virtual care visit that they cannot be helped virtually and that they will have to come into the office. This can be avoided in many ways:
  • Educating staff who book appointments to ask more questions of the individual to ensure what they need matches what can be provided virtually
  • Posting information on the practice’s website that shows what works well for a virtual visit (a prescription refill, a question about pain) versus what does not (ie: examining a wound) – that way, patients will have the right expectation
• The vast majority of people have not had a virtual visit so it would be very helpful to have a “what to expect” document or video available to patients so that they can review it ahead of their visit. It could also have information about what documents they should have ready (ie: list of medications or the actual medicine bottle, etc).
• The individuals preference for virtual care (communication modality for example) should be stored so that they don’t have be asked each time they try to make an appointment
• Some practices in the US have begun to loan out iPads and Chrome tablets to people who do not have a device capable of virtual care. There is a challenge of people selling them on the black market BUT if the doctor knows the patient this is very unlikely to occur.
• Some libraries in the US have begun to setup special private workstations where people can have virtual care visits – it’s a great way to use libraries – turning them into health hubs as book-reading continues to decline
• While waiting for virtual care appointments, why not show the person a video about healthy habits or about the latest research related to their condition. A diabetic, for example could benefit from a video on health food court choices. It would make use of the time they are online waiting.

Groups or individuals to engage in the future

Question: As we continue the work, whose feedback and participation would you like to see reflected in these Guidelines? Whose feedback do you wish was included or emphasized more? Is there a community, group, person or other we should engage in future Guideline work?

Response:

• There are many members of the healthcare ecosystem so it’s hard to include them all
• One group that would bring a unique perspective is government. They set the policies and the reimbursement rates. Right now, they have made an exception that make a virtual visit the same as an in-person one. This was done for COVID because people couldn’t come to see their doctors. BUT if they go back to what it was like before then there will be a financial disincentive for doctors to offer virtual care – since they are reimbursed at only a fraction of the rate of an in-person visit. It may be outside the purview of this Guide but something that talks about how to optimize reimbursement would help the viability of physician practices.

Guideline naming and clarity

Question: Naming the Guidelines is important for clarity and meaning. Please review the Guideline names and tell us from your perspective what you would change and what works well.

Response:

[ ... See response to next question ] I think changing from “Guide to Reducing Barriers to Virtual Care” would make the guide more popular.

Language and terminology

Question: Do you have any feedback related to any of the language and terminology used in the Guidelines?

Response:

Virtual Healthcare vs Virtual Care

The Guide uses the term “virtual healthcare”. Although technically correct, it is not the term used by healthcare media nor healthcare insiders. The more common term is “virtual care”. Just do a Google search for these two terms and you’ll see the difference. If you use the latter, this Guide will be more likely to be found and used by the audiences you are targeting.

I totally understand the desire to use the correct academic term. However, I would point to the experience Canadians have with the terms Electronic Medical Record (EMR) and Electronic Health Record (EHR). Technically, EMR only refers to the electronic storage of medical-related information (aka clinical information). What physician practices and hospitals use are EMRs.

EHRs on the other hand store health-related information which could include non-clinical data like diet, exercise regimens, the patient’s current mood or their socioeconomic situation. In Canada, policymakers and associations were very insistent on using the correct term. As a result many Canadian companies labeled themselves as EMRs.

However, most of the rest of the world adopted the term EHR and used it interchangeably with EMR. Unfortunately for Canadian companies, they did not appear in searches when people in the US and other countries went looking for EHR solutions.

The same could happen with your Guide. I would recommend using the term virtual care. Or at least sprinkle this term in places in the document to increase it’s searchability.