August 22, 2016 Ask Owen

In Canada the Doctor is Online, Anytime

On-demand telehealth is in growth mode in B.C. with a handful of businesses putting patients in video contact with a doctor over smartphones, home computers or in specially equipped consultation rooms.

A newly arrived business called MedviewMD from Chatham, Ont. has set up shop in four pharmacies in Kamloops, Langley and Chilliwack. Customers can quickly renew prescriptions by meeting via video link with a doctor in Ontario, and it’s all covered under B.C.’s medical services plan (MSP).

While telehealth — also called eHealth, telemedicine or virtual medicine — has been growing for years, it has ben mostly limited to video links between clinics from rural areas or First Nations asking big-city doctors for an opinion. Now a host of direct-to-consumer businesses are offering fast access to doctors from patients’ homes or the corner drugstore.

It’s either a boon to a health system that can’t provide a family doctor for every British Columbian or a path to publicly funded doctor shopping that’s just a few clicks away.

“It’s very promising in terms of the different types of technology, but I think we need to be cautious,” says Dr. Kendall Ho, a professor in the University of British Columbia’s faculty of medicine who now leads its Digital Emergency Medicine project.

“Cautious not to say, ‘stay away,’ ” says Ho, “but to be aware. And No. 1 is the fragmentation of care and services. Just because it’s convenient, does that mean it will be helpful to you or harmful to you?”

Risks include seeing different doctors each time so that there’s no long-term knowledge of the patient other than an electronic medical record that each online service stores for itself, says Ho. Worse, if the patient uses several different eHealth systems, doctors could inadvertently prescribe medications without knowing what the patient is already taking.

“From the health system’s point of view, would there be excess utilization? If the patient goes to the doctor and isn’t happy with that opinion, will they go seek a second opinion and a third opinion and a fourth until they find the opinion they need?” asks Ho.

For the taxpayer, telehealth’s ease of access is something that prompted a review by the Ministry of Health two years ago. That review has never been released, but has instead been wrapped into a provincial virtual care strategic plan that’s still in the works, says ministry spokesman Stephen May.

Health Minister Terry Lake was not available for comment.

In general, the government supports digital communication including texts, emails and videos for health care — particularly for people who have trouble getting to a doctor — as long as it’s private and secure. 

eHealth graphic for Erin Ellis piece. Source: B.C. Ministry of Health. [PNG Merlin Archive]

Most recent statistics from the ministry show telehealth visits billed to MSP plateaued at 26,252 in the most recent fiscal year, down slightly from 28,003 in 2014-15, following two years of explosive growth. There are no limits on telehealth in B.C. and it’s largely left up to doctors to decide whether it’s being used properly.

May said a key component of an optimal virtual care system is a single electronic patient record accessible to a regular team of health care professionals. But that remains a distant goal. The Vancouver Island Health Authority is testing a single electronic health record system in Nanaimo as a prototype for the rest of the province. Doctors there have complained that it’s not working adequately to protect patient health so it’s also under review by the ministry.

Virtual care

Telehealth providers say disjointed care from a rotating cast of distant doctors need not happen if it’s used appropriately.

Dan Nead, CEO of MedviewMD, says patients can request the same doctor after an initial visit and schedule followup appointments in advance. MedviewMD differs from typical video consultations because it takes place in a set location, adjacent to a pharmacy, and employs nurses who use blood pressure monitors, stethoscopes or devices to measure oxygen in the blood and then feed that information into records shared with the doctor.

“We can commit one of our doctors to you,” says Nead, a self-described ‘Bay Street Guy’ with a background in stock market trading. “We’re working toward dedicating doctors to the same regions, to the same locations, so that idea of having a physician who knows your history and has quite likely seen you in the past is available.

“It all circles around the continuity of care. If you cannot provide followup scheduled appointments, then you’re a walk-in clinic,” adds Nead, whose company has 11 locations in Ontario in addition to the four in B.C., with 19 more planned across this province, Alberta and Ontario.

But the best use of direct-to-consumer eHealth is still up for debate. There is little academic research testing its effectiveness and what is available is rapidly out of date in the fast-changing world of communication technology.

Kelowna-based software company QHR has pioneered electronic medical records in B.C. and in 2014 purchased Medeo, a Vancouver tech startup offering video conferences with doctors over smartphones, tablets or computers.

QHR CEO Mike Checkley says telemedicine is not a one-size-fits-all world and both patients and doctors must find which aspects work best for them.

For some, it will be making appointments online or having quick video check-ins with their local family doctor for a prescription refill or followup.

“I don’t think it makes sense for clinics to be exclusively online,” says Checkley, adding it can never replace a hands-on examination. “Virtual care is simply another way to have a visit between a patient and a doctor. We have to use it when it makes sense.”

Video visits

About 600 doctors in B.C. are using some aspect of Medeo’s software, he says. This includes Victoria pediatrician Dr. Adriana Condello, who says the program excels in mental health care — particularly for teenagers — by allowing patients, their parents or teachers to speak to her at convenient times without making a trip to her clinic. “It empowers the kids as adolescents. They say, ‘This is my appointment and I can do it.’”

She has about 20 patients using Medeo for some part of their care, but says the patients have to selected. “As practitioners we have to be cognizant that it can only be a certain part of the patient population because we can’t put our hands on them.”

That’s why some of the biggest supporters of telemedicine are in the areas of psychology and psychiatry, where a video visit can replace a counselling session — invaluable for people who don’t live in big cities.

Daniel Martz, CEO of Montreal-based Equinoxe LifeCare, says about one-third of his company’s 22,000 patients in B.C. used its EQ Virtual clinic for mental health issues. It launched here two years ago — also using Medeo software — after more than 20 years in Quebec’s homecare sector.

“The people who use it are from rural communities or who have disabilities and have a hard time going to the clinic.”

EQ Virtual has about 40 B.C. doctors treating patients in the province, says Martz. Many initial consultations end up being referrals to other doctors or services.

Two Vancouver doctors who founded the telemedicine company Livecare in 2013 say communications technology is revolutionizing health care, but direct-to-consumer services must be more than one-off prescription refills or consultations.

“The College (of Physicians and Surgeons of B.C.) will take a dim view of physicians who take part in that kind of health care,” says Dr. Mark Godley, an anesthesiologist involved in developing private medical clinics before creating Livecare. 

It focuses on telehealth for remote communities and First Nations and includes monitoring by local health care workers and regular in-person visits by doctors. 

Livecare chief medical information officer Dr. David Wilton, a hospital-based physician at Vancouver General, says telemedicine can’t deliver the best results unless there is some hands-on treatment involved. 

“Just doing virtual walk-in clinics is tempting because you can build volume, but it’s disruptive,” says Wilton. “It’s going to attract negative attention if that’s the business model.”


Watching vital signs at home can keep patients out of hospital

A specialized area of telemedicine called home health monitoring shows promise of preventing return visits to hospitals by people with chronic heart disease.

It has been tested and tweaked for eight years on 500 patients in the Vancouver Island Health Authority and will soon expand to the whole health region, says Lisa Saffarek, who heads the Island program.

“We studied our first 200 patients and we showed a 50-to-70-per-cent reduction in acute care utilization — emergency visits, hospital admissions and length of stays. We showed a cost prevention of $12,000 per patient, comparing three months before using the service with three months after,” says Saffarek. “So a huge impact.”

The home equipment includes a scale, blood pressure and blood oxygen monitors hooked up to a tablet computer, all supplied by Telus Health. A health care team sets limits for each reading and once a patient takes the daily measurements, they’re uploaded automatically to the tablet and a nurse watching the file. If the readings are too high or too low — or don’t come in at all — the nurse gets an alert that prompts a phone call to find out what’s wrong.

“You get immediate feedback that you just don’t get any other way,” says Saffarek.
Nanaimo heart patient Maurice King, 89, using the home health monitoring system offered by Vancouver Island Health Authority. PNG

Nanaimo heart patient Maurice King used the home health monitoring system for three months last year after being sent to hospital twice in less than a month for excess fluid on his heart. The 89-year-old says it made him much more aware of what sets off his problem.

“When you get a second kick in the butt, you pay attention,” says King. “Now I don’t take salt. I stay away from sugar. Every morning when you do this test it reminds you of the things you have to do each day to recover and stay well,” says King.

“I’m not on the program anymore but I’m continuing the lifestyle I developed in those three months, whereas the first time I came home, I didn’t. I went back to my normal lifestyle which was: have a scotch, have a ball and what the heck?”

He lost 15 pounds and now walks twice a day. He says it also took some of the caregiving pressure off his 69-year-old wife when he was able to ask an expert for health advice any day.

provincewide four-year research program will be launched this fall by UBC ‘s Digital Emergency Medicine program that will test the same equipment’s ability to reduce the number of patients who return to hospital after ending up in the emergency ward.

This article originally appeared here.

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