|Dr Kathleen Ross
Historically, physicians were viewed as the go-to experts for advice and reassurance about medical conditions and often social/psychological issues as patients navigated their lives. The trusting long-term relationships between primary care physicians, patients, and communities were the cornerstone of this process. Doctors were expected to be the all-powerful Oz, dispensing valuable medical advice and choosing the best treatment methods. Recently, however, Dr Google has demystified and democratized medical knowledge. The Internet makes high-level knowledge available to the masses, but is this always helpful?
At a recent CMA Health Summit in Toronto, titled Connected in Care, there was a great deal of discussion about virtual care and patients’ interest in the topic from the standpoint of access and convenience. Patients want to be informed, active participants in their health care. Physicians, governing bodies, and patients acknowledge that technology has the power to change the interactions between patients and their providers. Technology has the ability to empower patients. It allows them to better track their own health care indicators, including heart rate, activity levels, nutrition, blood glucose, etc. It can also improve health care delivery. The Ontario Telemedicine Network (OTN) pilot project, for example, allows patients who have an eating disorder to use an app to track their symptoms, interact with family physicians, and improve their participation in care.
But what risks does technology bring? Consumerism is driving change in all areas of our lives: banking, shopping, traveling, etc. It’s a societal shift that is also altering how patients want to seek care. Much has been made of the need for physicians to improve their uptake of technology in medicine and reduce the many barriers for adoption. It is equally important that we consider the management of patients’ expectations. How do we ensure that patients don’t view virtual care carte blanche—as an all-access pass to health care? There are times when accessing virtual care makes sense, such as in remote and home-bound cases. But there are times when it may be easier for the patient to use their phone and not travel to the clinic and then often wait. Home-based self-monitoring programs under development in BC, such as TEC4home, should help reduce the number of times a frail or home-bound patient would visit a clinic to manage their chronic disease. With three frail elderly parents in my family, I see the benefit. However, we must ask questions of cost and sustainability. How do we teach patients to use tech appropriately and how do we make patients accountable? Will such access result in increased use or the need for an in-person consultation to follow the virtual visit when patients literally have a doctor in their pocket? How can a system that is already struggling for resources support duplication of services? How will care providers be compensated in a system historically built to suit in-person interactions? Should virtual care be compensated the same way as in-person care that requires an examination? Who should fund this type of interaction? Will this be the final step toward a private subscription service fee in our publicly funded health care system? What about equity for marginalized populations?
Patient safety issues for those accessing virtual episodic care also need to be considered. Patients will need to learn to identify when it is appropriate to see a doctor remotely versus in person. I have seen medication renewals for statins, hormone replacement, and thyroid medications without appropriate review of investigations, such as lab tests, pap exams, or a mammogram. Sending me a notice could trigger me to review these files and recall for the needed care in my after-hours time.
Virtual care providers will need to be better at screening and identifying when it is safer for patients to be seen in person. The “deep learning chat bots” or “augmented intelligence engines” already in use could help eliminate patients for whom virtual care is not appropriate before they ever speak to a provider. Pattern recognition is important; however, reading the patients for underlying social issues or stressors is best done face to face.
How will we address the critical need to ensure continuity of care for medically complex patients when so many studies show that this longitudinal care is better for patients and saves health care dollars? One of my patients recently had several tests ordered by a virtual care provider that had already been completed in my office. As the primary care physician, it falls to me to follow up on any tests ordered by virtual care in my nonclinical time. Should the virtual care provider fund my time to review their work? I am aware of similar experiences from other physicians. I recently decided to track how often I saw patients and didn’t actually examine them or refer to their chart for timely investigations, either related to chronic disease or screening. I was surprised that there were none over the course of several office days. Having said that, if I could have incorporated their personal wearable device data into their EMR, where the data is analyzed and summarized ahead of the visit, I could have renewed a few medications remotely. The increased murmur leading to the diagnosis of a dilated aortic root would have been missed; however, in the greater scope of practice this example is rare.
The CMA Health Summit highlighted that we need greater connectivity in our health care system. As with any new innovation, there is an uphill struggle to implement—as we all experienced and continue to experience implementing our EMRs/EHRs. The motivator lies in the understanding that once we get past that obstacle, we will somehow be better off. This remains a debatable issue in some physicians’ offices.
Physicians may no longer be viewed as the sole keepers of health care knowledge, but our role as trusted care providers and companions for patients on their lifelong health care journeys is not so easily replaced. Let’s support ongoing development of technology that provides better access to care and seamless sharing of health care data in a way that makes sense for patients and their families. Let’s not forget to include and value the important part physicians play as we implement the many technological evolutions headed our way. Even with the curtain down, we are still Oz.
—Kathleen Ross, MD
Doctors of BC President