The Evolution of Virtual Care in Alberta

Clinicians in Alberta have been delivering virtual care for at least 25 years.

Before the advent of high-speed internet and smartphones, in the late 1990s, clinicians were communicating with patients via video conferencing by using dedicated telephone lines connected to video conferencing equipment in provincial healthcare facilities.  The technology was not ideal and required both patient and provider to travel to a facility to attend appointments.  Consequently, less than 1% of all outpatient clinical care in Alberta was conducted virtually.  Nevertheless, in addition to ambulatory care, some clinical areas have also developed services to enhance access to specialty care in rural regions. Some examples are; the Stroke Ambulance Service, video consultations provided by neonatal ICU physicians to newborns in distress in rural and remote regions, telepsychiatry in-patient consults between remote facilities, remote tele-rounding between urban pediatricians and outlying rural facilities, and virtual hospitals at-home care.

The Covid-19 pandemic rapidly changed the landscape.  Almost overnight, video conferencing tools leveraging smartphones and tablets allowed “Anytime, anywhere care” as the province entered lockdown.  Patients and providers alike were advised to avoid all unnecessary physical contact.  The Alberta government implemented fee codes to allow physicians to be compensated for virtual care.  These initiatives immediately provided the right ingredients for virtual care to rapidly grow.

During this time, several reassuring trends emerged.  Initial concerns that virtual care would result in unnecessary overuse were not substantiated.  While virtual care volumes increased from 2% in 2019 to 29% by 2021, the overall number of ambulatory visits remained constant, suggesting that some in-person visits were, in fact, replaced by virtual ones.  Naturally, higher acuity types of care had higher rates of in-person care owing to the requirement of a physical examination.  Some specialties, however, saw up to 80% of all out-patient care delivered virtually.  In 2022, volumes of virtual care in the ambulatory setting dropped to 22%.  This was an interesting observation, as compensation rates did not change. One can only conclude that practitioners are recognizing the limitations of virtual care and developing an awareness and understanding of clinical appropriateness.

In Alberta, patients have long been advocating for virtual care from their physicians for prescription renewals, test result reviews, and other medical concerns not requiring a physical exam.  A survey conducted by albertapatients.ca in February 2021 indicated that while 73% of patients are likely to use virtual care in the future, 59% are unlikely to use it in the context of virtual on-demand clinics without the ability to provide continuity or a physical assessment when needed.   Physician remuneration had been a barrier until March 2020.  Despite physician compensation modernization in Alberta for virtual care during the pandemic, some providers were concerned that certain diagnoses could be missed without a physical exam.  Other physicians have remarked on the erosion of work-life boundaries and video fatigue.

Furthermore, until now, healthcare providers have had next to no training in virtual care.  On a positive note, however, the province-wide AHS electronic medical record system being deployed through 2024 will provide sharing of patient health information across different providers and geographic zones, even though communication with primary care remains one-directional information access only at this time. In 2021, the Alberta Virtual Care Working Group, a body with multiple stakeholders from Alberta Health, Alberta Health Services, Colleges of Pharmacy, Nursing, and Physicians, Federation of Regulated Health Professionals, Indigenous peoples, and patient representatives examined the state of maturity of virtual care in the province, proposing design principles for virtual care.  Not surprisingly, with virtual care still in its infancy, when examining the technology, interoperability, leadership and governance, care models, and sustainability, we >90% of those surveyed in AHS Virtual Health reported very basic maturity.

So how will virtual care succeed in Alberta and beyond? 

Virtual care must not operate in a silo.  Providers and the system must not think of virtual care as something novel and exotic.  Virtual care is simply healthcare and must be integrated into the continuum of patient care needs.  Patients should not be arbitrarily separated into those that receive virtual care from one team of providers, and another team that provides in-person care.

So how will virtual care succeed in Alberta and beyond? 

1. Virtual care must not operate in a silo. Providers and the system must not think of virtual care as something novel and exotic. Virtual care is simply healthcare and must be integrated into the continuum of patient care needs. Patients should not be arbitrarily separated into those that receive virtual care from one team of providers, and another team that provides in-person care. Properly coordinating this care, allowing for patients to move dynamically and seamlessly between these two realms within the same circle of care is essential for the future; much like online banking is simply one form of banking in a larger host of financial services.

2. The system and government must decide on how to allocate resources for all of healthcare.  Is the virtualization of care simply for patient convenience, or does it actually improve access to care?  Alberta, very much like the rest of Canada, is in a crisis with a shortage of family physicians.  The data shows that despite the uptake of virtual care, overall clinical volumes have not increased.  This is simply because virtual care does not shorten a clinical encounter.

Often, more time is needed to ensure that critical details are not missed without a physical exam. 

3. There needs to be a robust evaluation strategy.  While there is plenty of data examining clinical encounter volumes, the evidence to prove that virtual care is safe, or cost-effective is either varied or absent.  Society, along with our healthcare system and elected officials, need to decide if we are after cost savings, improved access, or ideally both.  This can only be accomplished with reliable data on patient outcomes, and tangible and intangible costs to the system as well as to society.

Covid-19 has forever changed the way healthcare is provided.  Virtual care is here to stay.  For it to be sustained, we must align as providers, patients, and systems, to ensure that care is safe, equitable, clinically appropriate, and integrated with the rest of healthcare.