Maritime doctor

Conversation with Maritime Province Subject Matter Expert (November 25, 2020)

Main themes:

• Adoption / uptake of virtual care
• Virtual care platform benefits and challenges
• Onboarding / pre-loading patients
• Digital divide
• Organizing pilots, studies, and programs
• Wearable / RPM pilot
• Electronic health records

Adoption / uptake of virtual care

• Patients 55+:
  • do not see the benefit of virtual care
  • Virtual care process and software was found confusing
• Patients 20 to 55:
  • Virtual care was very natural for this group – a group familiar with online shopping
• There are some older patients who are “power users” – a future opportunity may be to recruit these individuals to help train others on the use of virtual care
• Trust in virtual care is a big issue. Market research explored issues with virtual care (eVisitNB|Maple specifically)–why did they not feel comfortable with it?
  • New-Brunswicker's wanted to get care from physicians they that knew. They wanted physicians who have an understanding of how they live, where they live and what resources they have available.
  • They also struggled with the technology. They didn't quite trust it.
  • A lot of people were older, which is most New-Brunswickers. They did not see how it worked and what benefit it would have. 
  • There is a huge digital divide. eVisitNB|Maple was not designed to be accessible by the masses. Need to re-think whether this is the right tool, the right interface because it is not working for them (older adults). Older New-Brunswickers want to use the tools that they know. They are certainly willing to be educated about what else is available.
  • Solution: they recruited physicians who were well known.
• Two main types of use cases:
  • Seeking advice – “Do I need to go to the hospital, or should I book an appointment?”
  • Chronic disease management or ongoing care (mental health, depression, medication management, scheduling lab work)
    

Virtual care platform benefits and challenges

• The platform itself is a commercial platform and is designed in a way that expects users to be paying customers. Thus designed requiring user accounts, and various security processes (register, confirm, 2-factor authentication, etc.) that may not fit well with broad, public healthcare.
  • Appointment based visits with a New Brunswick Doctor are FREE with a valid New Brunswick Medicare Card
  • On-Demand Consultations with a New Brunswick Primary Care Practitioner, Nurse Practitioner Appointments, Mental Health Therapists, Travel Health and Diabetes Management are not insured services under Medicare in New Brunswick and can be accessed for a FEE (e.g., $29....Nurse Practitioner Appointment, eVisit On-Demand from $49.00)
• Registration process causes a lot of friction for users, especially older patients.
• The platform is good for mental health checkins, blood sugar monitoring, medication, etc.
  • Virtual health can be used to screen for cognitive decline earlier – can intervene sooner with memory boosting regimen.
• Platform is available in English and French, and many doctors speak either English or French.
• Can be used in 3 manners: messaging, “telephone calls”, and video conferencing
  • Unclear if “telephone calls” refers to voice calls over the platform (like VOIP), or if a call is initiated to a physical telephone number.
• On the platform, they can see providers and choose – once they’re at this point it’s rather frictionless. Booking and attending is easy.
• Platform is cost effective for physicians as all booking and onboarding is done by the system and the patient
  • However, many doctors still use phone consultation as it is easy.
• “Micro-harvest” time from multiple providers to provide fulltime virtual healthcare
• A lot of the friction is at the beginning during registration.
• Virtual visits can help with patient’s memory, mental health, and loneliness. Volunteers and caregivers can drop in virtually.
  • Looking for ways to include remote family members in virtual care. Notable in cases where power of attorney is required / decision making.
• Other challenges:
  • Non-English / French interactions - A lot of visual and physical cues are missing virtually (like gestures).
  • No way of following up with patients on the platform, get feedback, or build relationships. Predominantly a solitary encounter.
  • Little way of knowing whether advice was beneficial for the patient.
  • Anything with a physical is challenging virtually.

Onboarding and pre-loading patients

• Integration with telephone health network
  • Looking to use regional health phone service as a way to onboard patients into the virtual healthcare platform and book appointments with the virtual healthcare providers.
• Increasing virtual health presence
  • Many older patients have healthy relationships / trust with their pharmacists, perhaps the pharmacy can become a location to provide virtual health if space is provided.
  • Other locations may include community centres, libraries.
• Simplify preloading process
  • Can’t be all online – book through phone, pharmacy, other physical alternatives
  • Receive intake information via video, phone, or messaging

Digital Divide

• Access to technology and usability of the platform causes a divide
• Rural parts of the province lack broadband, and dial-up is no longer available. LTE not widely available in parts. 3G may even be precarious.
  • 20% of population have spotty access to 3G / LTE
• Not everyone has an email address (virtual care platform requires an email to register)
• Everyone who has power utility service has a phone as they are tied together.
• Less than 1% of those engaged in virtual health are aboriginal – they can benefit from virtual health, but under represented.
• Virtual health has been used in the shelter system as there is internet access
• On poverty:
  • Look to where poverty and society interface – maybe a pharmacy, food bank, shelter, etc. and provide virtual health opportunities there
  • Convert existing spaces into safe, private rooms for virtual visits
  • Low budget - $200 Chromebook and space
• Opioid intervention
  • Virtual healthcare platform could be useful for opioid intervention
  • Needs to be easier than getting a drug – can’t schedule weeks in advance. Needs to be on-demand.
  • Pharmacies may be a possible place to get this help

Organizing pilots, studies and programs

• Virtual care pilot started with identifying leaders of care in the community to become champions / first service providers on the platform.
• Virtual health is effective, but requires data to back up the claim

Wearable / RPM Pilot

• RPM pilot using a wearable that monitors out patient’s biometrics, and links to an LTE tablet
  • Both wearable and tablet provided to the patient in the pilot
• Tablet software is reported to be "simple" has ways of contacting the clinician
• The Rountinify software provide haptic feedback for medication reminders and provides clinicians with real-time information.
• Information can be used to trigger interventions (for example, sudden weight loss/gain, missed medication, etc.)
• Onboarding of the physical system is done in person. Otherwise suspects it is too difficult for many patients.
• Future device possibilities include a scale that monitors weight (weight is also a good indicator of health)
• Goal - to see if it reduces hospital visits
• Currently ideal candidate is someone who is discharged from hospital, not in a rural area (due to LTE requirement)

Electronic Health Records

• Health record travels with the patient’s device so they have a local copy that is usable in other (emergency) situations.
• It’s possible to have collaborative health records where patient can add their own details. For example, if the patient visits the ER, they can record details of their visit so the next time they visit a doctor, they can see the updates.
• If a patient is going to the hospital, their medical record can be sent in advance to the hospital via the virtual care platform