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VIRTUAL CARE & DIGITAL HEALTH EVALUATION

Academic publications are in progress, however, if you would like a copy of any of the Ontario Ministry of Health-funded reports, please reach out to cdhe@wchospital.ca

Bringing Virtual Care Into Family Practice: The Enhanced Access to Primary Care (EAPC) Program

In 2017, the Ontario Ministry of Health undertook the Enhanced Access to Primary Care (EAPC) pilot program, which explored the uptake of virtual care by giving primary care providers a secure platform for voice, video, and asynchronous messaging to conduct eVisits with patients in Ontario. The Centre for Digital Health Evaluation (CDHE) evaluated the use of different modalities for care delivery along with the experience of patients and providers to understand barriers and facilitators to adoption. As part of the evaluation, providers were recruited across five different Ontario regions, with almost 200 providers enrolled in the program. Providers registered over 14,000 patients and conducted over 14,000 visits, with over 6,000 patients completing at least one eVisit over six months. This was the largest evaluation of virtual primary care in Canada at the time. The evaluation found that over 90% of eVisits to primary care providers used asynchronous text and most providers reported having few issues with patients using the platform inappropriately. Overall, patients reported that eVisits saved them time and money, and approximately 99% indicated that they would use this service again.

Exploring the Impact of the Digital Health Drug Repository (DHDR)

In 2016, the Ontario Ministry of Health created the Digital Health Drug Repository (DHDR), a database that consolidates patients’ medication history across Ontario. The Centre for Digital Health Evaluation (CDHE) evaluated DHDR’s impact and potential areas for improvement. The evaluation found that DHDR uptake was limited among eligible healthcare providers. Among those who used it, the DHDR was found most valuable during geriatric and surgical consultations, in the emergency department, and when prescribing medications to new patients and those with multiple diagnoses over the age of 65. To increase the adoption of the DHDR more broadly, the evaluation recommended improving the comprehensiveness of data to include private insurance claims and medication instructions, and integrating the DHDR into point of care systems to optimize workflow efficiencies.

This evaluation has been carried out by the Centre for Digital Health Evaluation (CDHE) hosted at Women's College Hospital Institute for Health System Solution and Virtual Care and funded by Ontario's Ministry of Health.

Regional MyChart Patient Portal in South West Ontario

In August 2018, the regional MyChart patient portal was funded by the Ontario Ministry of Health to go live in South West Ontario (SWO). This portal enabled patient access to their clinical information from multiple health institutions in the region. In 2019, the Centre for Digital Health Evaluation (CDHE) evaluated MyChart to explore experiences with the patient portal, identify challenges with implementation, recommend opportunities for improvement, perception of potential benefit, and key strategies for implementation success. A total of 43 interviews were conducted with a variety of stakeholders including patients, health care providers, and individuals involved in implementing the patient portal. Quantitative usage data was analyzed alongside the qualitative findings. This evaluation found that, while multi-institutional patient portals can enable efficient access to clinical information from multiple health services, successful implementation can be impacted by several factors. Factors that were seen to positively impact implementation included: a blanketed roll-out (instead of implementing across departments in a staggered manner) and strong support of senior leadership and clinical champions. According to the findings from this evaluation, in order to optimize the patient experience, data comprehensiveness should be prioritized, which requires a coordinated approach, aligned policies, and a key base of technology infrastructure that allows for interoperability across participating organizations.

This evaluation has been carried out by the Centre for Digital Health Evaluation (CDHE) hosted at Women's College Hospital Institute for Health System Solution and Virtual Care and funded by Ontario's Ministry of Health.

Virtual Care in the COVID-19 Era

In early 2019, the Centre for Digital Health Evaluation (CDHE) evaluated the uptake, impact and use of virtual care across the province of Ontario given changes in care delivery during the COVID-19 pandemic. Virtual care services in Ontario included the use of telephone, video, and asynchronous messaging between patients and providers. The CDHE evaluated the extent and impact of the rapid virtualization of clinical care on patient and clinician experience, and the overall cost and quality of the care provided through the following streams of work:

• Stream 1: What is the uptake and impact of virtual care across the province, across regions, and across patient populations?
• Stream 2: Does virtual care lead to inequitable access to healthcare services by underserved patient groups across different health settings?
• Stream 3: How has virtual care been used in primary care?
• Stream 4: How has virtual care been used in hospital settings?

Stream One: Health System

The goals of Stream 1 of the evaluation were to describe the changes in virtual care use that occurred in Ontario during the pandemic and to evaluate the impact of virtual care use on healthcare utilization and patient outcomes. To conduct this evaluation, the CDHE used health administrative databases housed at ICES (Institute for Clinical and Evaluative Sciences) containing population demographics, physician services, and patient healthcare utilization such as hospitalizations, emergency department visits, and lab and diagnostic testing. This evaluation found that the introduction of temporary billing codes for telephone and video in March of 2020 led to rapid uptake of virtual care in the province. Virtual care visits constituted at least 50% of all ambulatory visits in Ontario throughout the first ten months of the pandemic (March 2020 to January 2021). No differences were found in the utilization of virtual visits by neighbourhood income level, however differences were noted for other demographic groups, with higher uptake reported amongst females, urban patients, and older adults age 65 and above. Generally, patients who were high users of virtual care during the pandemic were also high users of the healthcare system before and during the pandemic.

Stream 2: Health Equity

The goal of Stream 2 was to explore the impact of rapid virtualization on equitable access to health care. To conduct this evaluation, the CDHE conducted case studies within five care contexts across the Ontario health system to explore implementation challenges of virtual service delivery and to understand how health equity was considered or neglected during this process. The CDHE also completed a scoping review of the literature to generate insights regarding the most salient barriers to engaging in virtual care among structurally marginalized communities. The findings of the case studies indicated that many organizations did not have extended engagement or training in topics related to health equity to draw upon in their implementation of virtual care and therefore did not always know what solutions to implement to break down barriers to care. In general, it was found that there was a lack of strategies by organizations to ensure access for individuals experiencing auditory, cognitive, or visual impairments, individuals encountering language barriers, and individuals experiencing homelessness. One of the clearest challenges in access to virtual care that arose in the scoping review and case study findings as part of this evaluation was the lack of access to and affordability constraints of the Internet, cellular service, and/or digital devices. Cost-related and infrastructural barriers were most apparent for those living in rural and remote communities, including Indigenous Peoples; and those who are low-income, including older adults on a fixed income and individuals experiencing homelessness. The evaluation team found that meaningful engagement with virtual care is only possible if patients, caregivers, and healthcare providers have the digital literacy to use the technologies effectively. However, many providers and service users may not have appropriate digital health literacy skills to engage in virtual care. It was found that phone calls were widely employed as a strategy to mitigate some of these challenges and served as a crucial tool to ensure equitable access to virtual care overall.

Stream 3: Primary Care

The goal of Stream 3 was to investigate the impact of the rapid virtualization of primary care during the COVID-19 pandemic. To conduct this evaluation, the CDHE included an environmental scan, interviews with patients, providers and administrative stakeholders, and a survey with patients/caregivers and providers. It also leveraged original studies by CDHE partners, including a survey of over 7,000 patients from 14 academic Family Health Teams (FHTs), and electronic medical record data from Community Health Centres (CHCs) across Ontario. This evaluation found that most healthcare visits during the COVID-19 pandemic were conducted by phone due to its convenience, with few visits conducted by video (due to set up and technical issues) or asynchronous messaging (because it was rarely offered and not a billable visit for physicians). Having to triaging patients to in-person or virtual care increased provider workload. The evaluation reported that patient and provider preferences for different modalities varied widely. Moving forward, it was found all participants envisioned a mix of in-person and virtual interactions in the future, ideally determined by patient preference and clinical appropriateness.

Stream 4: Hospital Systems

The goal of Stream 4 was to investigate the impact of the rapid virtualization of healthcare within hospital systems during the COVID-19 pandemic. To conduct this evaluation, the CDHE included four hospital sites: St. Joseph’s Healthcare Hamilton (SJHH), Women’s College Hospital (WCH), St. Michael’s Hospital (SMH), and Trillium Health Partners (THP). Data sources for this evaluation included aggregate clinic-level utilization data, qualitative interviews with patients and providers, and virtual care experience surveys distributed to patients and providers across diverse specialty areas. Evaluation findings indicated that the key benefit of virtual care was the convenience and cost savings produced for patients (e.g., by not having to travel, pay for parking, or take time off work), and reducing patient no-show rates for appointments, along with avoiding COVID-19 transmission in public spaces. The evaluation found that preferences for different virtual modalities vary widely among and between patients and providers and depend on context (e.g., clinical area, access to and comfort with technology, and other work/life responsibilities).

This evaluation has been carried out by the Centre for Digital Health Evaluation (CDHE) hosted at Women's College Hospital Institute for Health System Solution and Virtual Care and funded by Ontario's Ministry of Health.

​HEALTH SYSTEM & POLICY INNOVATION

Innovative Integrated Care Globally

Working with researchers at the University of Toronto’s Institute for Health Policy, Management and Evaluation (IHPME), WIHV surveyed 30 innovative integrated care programs for patients with complex needs in 11 countries. Our team developed a survey tool, collected and interpreted the data to create briefs about the design features of each program and their policy context. Through this initiative with the Commonwealth Fund, our team was able to leverage best practices globally to gain better insight into how new models of care can better support patients with complex needs.

Toronto Neighbourhood Care Initiative

Under our current health system, socially and medically complex patients often face difficulties receiving continuity of care. The Neighbourhood Care Initiative is an integrated care pilot project in 10 neighbourhoods across Toronto that is developing highly-coordinated, patient-centred models of care. Teams are made up of home and community care organizations, social service agencies and primary care partnerships. WIHV is conducting a multi-year developmental evaluation of the initiative.

IMPLEMENTATION SCIENCE

Low-Value Care with Choosing Wisely Canada

Up to 30 per cent of tests, treatments, and procedures done in Canada are potentially unnecessary. Choosing Wisely Canada is a national initiative taking action against low-value healthcare. WIHV works as the measurement and evaluation lead of Choosing Wisely Canada, where our research involves quantifying rates of overuse and assessing the impact of low-value care on patient outcomes. These findings are contributing to the development and implementation of solutions to improve quality of care. In a recent study, published in JAMA Open, we found that, within Ontario, there was a small group of “frequent users,” comprised of roughly 18 per cent of all primary care physicians in the province, ordering over 32 per cent of low-value screening tests.

The Ontario Healthcare Implementation Laboratory

Working with multiple provincial organizations and agencies, WIHV is leveraging data to evaluate large-scale quality improvement activities in the health system. Currently, the team is investigating the role of family doctors in improving opioid prescribing practices. We have found that there is a clear opportunity for better intervention strategies targeting family physicians, in order to more effectively support them in managing patients’ with a high-risk opioid prescription. Our initial findings have been published in BMC Family Practice and Annals of Family Medicine.

Proactive, Personalized Postpartum Mental Healthcare (P3MH)

Mental health symptoms are very common in new parents, affecting close to 20 per cent of mothers and at least 10 per cent of fathers. When these symptoms progress to severe levels, they can become more difficult to treat. Our study uses software that integrates with electronic medical records and delivers secure email to engage parents in assessing their mental health symptoms. Online surveys are sent on behalf of family doctors and are used to support the development of a tailored care plan that includes customized resources for both patients and family physicians. The study is taking place at 5 family health teams across the greater Toronto area. We are currently enrolling patient participants.

P3MH is a part of WIHV’s Proactive, Personalized Self-Management & Decision Support (PPDS) program. Read More

WOMEN’S COLLEGE HOSPITAL CLINICAL EVALUATION

Screen While You Wait: Physical Activity

We know that exercise is an effective way to improve health. Yet, only 18 per cent of adults get the recommended amount each week. For this study, patients at WCH’s Family Practice Health Centre completed an online survey, which was used to support the development of a tailored care plan, including the provision of an “exercise prescription” and a toolkit with online and community-based resources. The Screen While You Wait study demonstrated that digital tools can provide patients with tailored resources to improve healthy behaviours. Study findings have been published in Canadian Family Physician and the Journal of Medical Internet Research.

Screening While You Wait 2: Tobacco and Alcohol Use

The best approach to reducing substance use involves routine screening, short discussions with clinicians, and offering people tailored resources to help them. Unfortunately, primary care providers often do not screen or provide evidence-based interventions to their patients. Building on the first iteration of Screen While You Wait, patients at WCH’s Family Practice will be emailed a secure link to a survey with question assessing their substance use and other important contextual factors prior to an upcoming, non-urgent appointment. Results will be summarized in their chart and an automatic notification will be sent to their doctor when that occurs. If the survey reveals concerns, both parties will receive a package of tailored resources for further care through an innovative website. This study is currently underway at WCH Family Practice.

Both Screen While You Wait studies are a part of WIHV’s Proactive, Personalized Self-Management & Decision Support (PPDS) program.

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