Telemedicine in primary care: Who are the current users in British Columbia?

Background
Telemedicine has been defined as “the provision of medical expertise for the purpose of diagnosis and patient care by means of telecommunications and information technology where the patient and provider are separated by distance.”[1] Although telemedicine has existed for decades, it has become more popular in recent years. The most commonly used telehealth services are those associated with mental health, cardiology, diabetes, genetics, oncology, neurology, and rehabilitation.[2] Evidence indicates that telemedicine can be a safe option for providing health care and can lead to many favorable outcomes.[3-7] The College of Physicians and Surgeons of BC and the BC Ministry of Health have acknowledged the role of telemedicine and recognized the opportunities and limitations of technology-based patient consultations.[8,9]

Despite the undeniable benefits of telemedicine, one study found that doctors providing direct-to-consumer care were less likely to order diagnostic tests and had poorer performance on appropriate antibiotic prescribing for bronchitis.[10] As well, the BC Ministry of Health notes that the fragmented, unmanaged approach to the expansion of telemedicine has led to increased Medical Services Plan costs.[9]

In both BC and Canada as a whole there is a lack of information on the current use of telemedicine and the demographic characteristics of users in primary care. The most up-to-date and comprehensive review of telemedicine in primary care was done by the Canadian Agency for Drugs and Technologies in Health in 2008. This review identified a lack of sufficient information about cost-effectiveness, access to the service, resource utilization, process of care, and patient satisfaction.[11] Since 2008 there has been significant growth in telehealth technologies and expansion of services. The 2015 Canadian Telehealth Report states there was aggregate growth of 45.7% in the volume of clinical sessions between 2012 and 2014.[2] Despite the potential benefits of virtual care in BC, where the technology that enables delivery of telemedicine services is provided through private companies, overall use remains very small (0.01%).[12]

We undertook a study to appraise the role of telemedicine in primary care in achieving maximum benefits for both patients and the health care system. We sought to determine the demographic characteristics, geographical distribution, and medical concerns of current users. 

Methods
We obtained data for our study from the largest telemedicine provider in primary care in BC, Quality Health Technology (QHT), previously known as Medeo. The data described patient consultations conducted using the Equinoxe Virtual Clinic platform. Approval for the study was received from the UBC Clinical Research Ethics Board.

QHT provided us with anonymized patient data: ID number, age, gender, place of residence (pharmacy postal code), total number of consultations overall, number of consultations per patient, and the ICD-9 or Society of General Practitioners (SGP) diagnostic codes used for billing each consultation. The data provider excluded any confidential information, including patient name, personal health number, and address. We created one data set by aggregating the gender and age data for 26 months (September 2013 to October 2015) and calculated the total number of users for two periods designated 2013–2014 and 2014–2015. 

Descriptive statistics were used to analyze the current use of telemedicine. The characteristics of users and usage needs were summarized by calculating the number and distribution of users by BC regional district (RD). Continuous variables such as age and health service use were summarized by calculating the mean and range. Gender was evaluated by percentages of the total cohort. Categorical variables such as place of residence were summarized by frequency and percentage, taking into account the population of each region in 2015 according to the BC Stats website.[13] We identified the most common medical concerns addressed during consultations using Microsoft Excel to sort all ICD-9 and SGP diagnostic codes by frequency, and then we regrouped the subcategories of medical concerns into larger categories by frequency to find the top 10 concerns. 

Results
Data were collected for telemedicine users in 29 BC regional districts (Table 1). The number of users increased from 8282 in the first year of the study to 17 149 in the second year, for a total of 25 431 users in a 2-year period (Figure 1). The total number of consultations was 79 576, and the number of consultations per patient varied from 1 to 83. The mean number of consultations was 4.6 (5.3) and the median number was 3.0.

Detailed analysis of data from the second year of the study revealed that 11 025 of the 17 149 patients (64.3%) were female. The age of patients ranged from younger than 1 year to 100 years, with a mean age of 31.5 (14.5) years and a median age of 31.0. Approximately three-quarters of users (75.3%) had one to five consultations.

Of 14 011 users whose place of residence was documented (81.7%), the largest number were from the Greater Vancouver RD (7221 users, 51.5%), followed by the Peace River RD (3316 users, 23.7%), the Fraser Valley RD (977 users, 7%), the Capital RD (760 users, 5.4%), and the Thompson-Nicola RD (490 users, 3.5%) (Figure 2). Telemedicine users in these five regional districts made up 91.1% of all users, while only 8.9% of users were located in the other 24 regional districts of BC. The highest rate of telemedicine use was found in the Peace River RD in Northern BC, followed by the Thompson-Nicola RD, Fraser Valley RD, and Greater Vancouver RD (Table 2).The cities in the Greater Vancouver RD with the largest number of users were Vancouver (36.3%), Surrey (16.2%), Burnaby (9.4%), Langley (8.6%), and Coquitlam (6.5%). In the Peace River RD the majority of users were located in Fort St. John (97.5%). In the Fraser Valley RD, the cities with the most telemedicine users were Chilliwack (47.7%), Abbotsford (35.1%), and Mission (12.9%). 

We were provided with 33 159 diagnostic codes submitted for billing purposes from October 2014 to October 2015, and identified 16 151 of these (48.7%) as examples of the top 10 concerns (Table 3). The three most common concerns were anxiety/depression (12.6%), contraception (8.3%), and skin problems (6.0%). 

Conclusions
Several findings from this study are worth highlighting. 

First, the young average age of telemedicine users (31.5 years) was not unexpected, given that younger individuals are more likely to use modern technologies, possibly due to the electronic literacy required of most working adults today. In future, exploring ways to enhance patient electronic literacy might be considered to facilitate equitable access to telemedicine across all age groups. 

Second, the age and location of users in the study may have been affected by the way data provider QHT, the first private organization to offer a direct-to-consumer telemedicine service in BC, chose to market their service. In future, marketing may speak to users of different ages and locations. 

Third, the most common medical concerns addressed through telemedicine identified by this study were anxiety/depression and contraception. The Medical Council of Canada reports that anxiety is the leading diagnosis in Canadians age 19 to 44. Furthermore, according to the literature, the lifetime incidence of depression and anxiety is higher in females of fertile age.[14] In the same age group, contraception is the fifth main concern of those seeking help in outpatient settings.[15] It is thus not surprising that the majority of users in our study were females of reproductive age and that the most common concerns were anxiety/depression and contraception. This suggests that the concerns of young women using telemedicine for primary care were the same as those of young woman using traditional medical services for primary care.

Fourth, possible reasons for the heterogeneous distribution of telemedicine users across BC need to be explored further. Knowing that “less than 10% of physicians practise in rural areas whereas about 18% of Canadians live in rural areas,”[16] we had hypothesized higher use of telemedicine in rural areas to make up for a gap in care in these communities that could be filled by telemedicine. Our finding that the highest rate of use was in Northern BC may indeed be explained by limited access to the health care system and lack of health care providers in that region. However, other factors may also have determined the distribution of users, including level of Internet access, increasing use of mobile devices, and exposure to marketing through social media. A recent systematic review shows that the feasibility and acceptance of telemedicine for use in primary care varies significantly with demographic variables. 

Finally, although the rapid uptake of telehealth over the 2-year study period supports patient acceptance and interest in telemedicine in primary care, it is worth noting that telemedicine has often been found more acceptable to patients than to health care providers.[17] 

Study limitations 
This study is the first published that we know of to describe the demographic characteristics and most common medical concerns of telemedicine users in BC. The study had several limitations, including our analysis of data from a single private telemedicine provider. The need to infer the true nature of users’ medical concerns from billing codes, many of which are very broad, was another limitation. The need to identify user place of residence using pharmacy postal codes, which may not reflect where users live or where providers practise, was also a limitation. Additionally, we had no data on how many physicians were involved in providing telemedicine services in BC. 

Further research involving all telemedicine providers is required to provide more accurate estimates of demographic characteristics and service needs in primary care in BC. Ongoing monitoring of use will also help to assess the current impact of telemedicine on the provision of primary care and the role of telemedicine in future.

Summary
The number of primary care telemedicine users in BC grew from 2013 to 2015, with usage doubling from 2013–2014 to 2014–2015, the years studied. The majority of users were younger than 50 and were distributed broadly in urban and suburban areas, with the highest rate of use in Northern BC. The most common concerns of users were related to mental health and contraception. While more research is needed, these results suggest that telemedicine has a role to play in providing primary care throughout the province.

Acknowledgments
We would like to thank James Jiu, MD, CCFP, who provided valuable insight into the discussion of telemedicine use in BC,  Kimberlyn McGrail, MPH PhD, scientific director, Population Data BC, and Nancy Gabor, MSc, PMP, CPHIMS-CA, who reviewed the paper and provided valuable feedback.

Competing interests
None declared.

This article has been peer reviewed.

Dr Terekhova is a PGY-2 resident in Family Medicine at the University of British Columbia IMG-St. Paul’s Hospital site. Dr Tabassi is an ER physician in Dawson Creek and clinical faculty in the Department of Family Medicine at UBC. Dr Gabriel is a clinical associate professor in the Department of Family Medicine at UBC. Dr Jafari is clinical faculty in the Department of Family Medicine at UBC and addiction and mental health physician at the Burnaby Centre for Mental Health and Addiction.