Volume 7 no 2
Principle-driven virtual care practice to ensure quality and accessibility
Kendall Ho, MD, Ken Harris, MD, and Toni Leamon
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Principle-driven virtual care practice to ensure quality and accessibility
Kendall Ho, MD, Ken Harris, MD, and Toni Leamon
https//doi.org/10.37964/cr24733
COVID-19 has accelerated the use of telehealth or virtual care (VC) as an alternative form of health care delivery. Clearly, VC provides unprecedented convenience and timeliness for patients seeking care from their health professionals. As a result, a substantial increase in telehealth providers is occurring, and the Canadian government is investing millions to support digital health care treatments and telehealth services. However, it is vital that the health professional community carefully examine the quality of care being delivered digitally and determine when it is appropriate to use VC as an alternative to face-to-face care. This article highlights some principles for health policymakers, health professionals, and health consumers to consider to ensure that VC is used appropriately and ethically for the right health conditions and in the right contexts.
KEY WORDS: virtual care, COVID-19, telehealth, quality of care, medicolegal issues, training, policymakers
CITATION: Ho K, Harris K, Leamon T. Principle-driven virtual care practice to ensure quality and accessibility. Can J Physician Leadersh 2020;7(2):81–84.
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Clearly, VC provides unprecedented convenience and timeliness for patients seeking care from their health professionals, one of five key trends that will influence growth of telehealth.3 As a result, a substantial increase in Canadian telehealth providers is occurring, and the federal government is investing $13.4 million to support digital health treatments and telehealth services.4
In this time of VC boom, it is vital that the health professional community carefully examine the quality of care being delivered digitally and determine when it is appropriate to use VC as an alternative to face-to-face care.5 This article highlights some principles for health policymakers, health professionals, and health consumers to consider to ensure that VC is used appropriately and ethically for the right health conditions and in the right contexts. Top
Principles of virtual care
Although it is acceptable to challenge traditional thought, the use of VC should always be anchored on the principles that underpin the practice of medicine itself. Modern information and communication technologies should only be considered as tools to facilitate and optimize care. Their use should benefit our patients and do no harm — a fundamental tenet of medical practice.
The following key principles differentiate VC from in-person practice. They should be considered in the education of health professionals and trainees to support sensible adoption of VC in health care delivery. The principles fall into four domains: clinical, medicolegal, andragogic, and social. Top
Clinical
Clinical quality optimization
Judging whether to choose VC for health service delivery should be based on whether it is a reasonable or better option than in-person encounters in providing safe, accessible, timely, and high-quality health care to patients.
Considerations include:
- likelihood of accessing in-person care (e.g., patient is in a rural location where timely in-person care is impossible)
- quality, quantity, and reliability of information acquisition
- sufficiency of peripheral observations of the patient
- absence of direct physical examination for clinical decision-making and, in some instances, for meeting the standard of care
- potential of VC to impair judgement or introduce bias in decision-making
- incorporation of current best practices and accepted standard of care in VC Top
Communication facilitation
Like other communication tools used in medicine, VC should support or enhance communication with patients to augment information gathering and relationship building.
Considerations include:
- optimizing accuracy in history taking
- sharing of diagnosis and management details with patients
- building a relationship of trust with patients and families
Continuity of care
VC encounters should be considered as time points in a continuous string of interventions in longitudinal patient journeys. Top
Considerations include:
- establishing a clear process for patient follow up after the VC encounter
- arranging clinical handover of patient information to other health professionals after the VC session, e.g., rural-urban health professional handovers or interprofessional handovers in team-based care
Medicolegal
Informed consent
When engaging patients in the use of VC, adequate disclosure of benefits and risks is necessary, so that they are fully informed and not acting based only on perceived advantages (e.g., convenience, travel avoidance).
Considerations include:
- proper risk disclosure, frank discussion with patients, and opportunities for them to ask questions
- documentation of informed consent
Confidentiality and privacy
Patient privacy and maintenance of confidentiality of information exchange must be preserved through VC, just as it is for in-person care.
Considerations include:
- ensuring the use of secure software and communication infrastructure during patient–physician exchanges
- storing information and preventing unauthorized access by third parties
- maintaining a proper VC record and its availability to patients and caregivers and for medical auditing
Consistency with the legal/regulatory frameworks
Choosing VC should take into account the current legal and regulatory frameworks, including:
- jurisdiction of practice and licensing
- existing telemedicine/VC professional practice guidelines
- privacy and confidentiality guidelines and recommendations
- maintenance and retention of a proper medical record
Transparency of VC involvement
Establishment of a clear and mutual understanding is important to all parties involved, including health professionals and learners, patients, caregivers, and the health care system.
This transparency should include:
- clear expectations about response times and “when the virtual office is open”
- licensure mechanisms to facilitate the process
- medicolegal protection
- clinical boundaries of acceptable VC care
- service reimbursement
- choosing appropriate software or infrastructure for appropriate VC use by the health system, health professionals, or patients with full understanding of the implications Top
Competency-based training
VC education for health professional trainees should consider a spiral curriculum, starting from simple cases (e.g., a single-image-based, one-on-one consultation) to more complicated cases (e.g., a team approach with several interdisciplinary colleagues participating simultaneously) and then to complex settings (e.g., providing VC to a remote community with low bandwidth and complex health service needs).
A variety of training options can be deployed, including:
- didactic learning of principles
- patient encounters for experiential learning
- standardized patients for simulation-based training
- scholarly projects to explore innovations or controversies
The planning and implementation of curriculum, training content, and educational methods would benefit from co-creation with and participation of patients, caregivers, and communities. Practising health care professionals would also benefit from continuing professional development in VC. Top
Harmonization with curricular priorities
VC training need not be done in isolation, but can be creatively harmonized with other competencies to generate strong synergy. For example, VC can be illustrated, taught, and experienced in combination with interprofessional collaboration, ethics, or rural and remote medicine. Top
Life-long learning commitment
VC education and knowledge exchange should take place in the continuum of undergraduate, postgraduate, and continuing professional development domains. Group-based dialogues, such as forums, can provide opportunities for sharing of clinical pearls, lessons learned, latest innovations and research, and challenging controversies. It is also important to encourage mentorship provided by experienced clinicians well versed in VC to colleagues and trainees to perpetuate VC best practices longitudinally.
Social
Contextual sensitivity versus universality
Integrating VC into different aspects of health care services requires the meticulous consideration and selection of modes for use in special contexts to achieve equity of access and quality of care, for example, in rural and remote settings, urban isolated situations, mobility issues, socioeconomic constraints, etc. Health professionals providing VC must always be aware that not all patients have the same access to technology, because of variability and availability of resources or infrastructure in different communities and contexts. Top
Return on investment for all stakeholders
VC should be carefully deployed only in the appropriate context and situation to enable and enhance patient care, as not every aspect of health care services will fit. VC should not be chosen for expediency of care or convenience alone. Health professionals and involved health organizations must also be appropriately remunerated and compensated for the use of VC, but economic gains should never supersede excellence in quality of care.
Social reform and continuous quality improvement
Tomorrow’s best practices in VC will certainly be different from those of today through technological innovation and evolution, and new understanding and lessons will be generated from expanding clinical applications. All stakeholders must be adaptive and flexible, as new technologies and VC approaches emerge. They must be effective change agents to promote sensible VC adoption, advocate evidence-informed VC to improve care, and engage in the co-creation of the future standard of care through continuous quality improvement.
Conclusion
We hope these principles will be helpful in guiding thinking toward the future evolution of VC toward high-quality best practices that also support convenience and equity of access. We welcome readers’ feedback and further socialization to arrive at core principles that all stakeholders feel are important to illuminate on the path to future excellence in VC. Top
References
1.Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: a quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company 2020;29 May. Available: https://tinyurl.com/yxr3ws9d
2.Virtual care is real care: national poll shows Canadians are overwhelmingly satisfied with virtual health care. Canadian Medical Association News 2020;8 June. Available: https://tinyurl.com/y47d34hw
3.Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med 2017;377(16):1585-92. https://doi.org/10.1056/NEJMsr1503323
4.George-Cosh D. Canada’s telehealth boom in ‘early innings’ as COVID stokes demand. BNN Bloomberg: Company News 2020;15 Oct. Available: https://tinyurl.com/y5epul72
5.Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med 2020;382:1679-81. https://doi.org/10.1056/NEJMp2003539
Acknowledgements
We acknowledge the assistance and commentary provided by Douglas Bell, MD, of the Canadian Medical Protective Association in the preparation of this article. We also acknowledge the roles of the Canadian Medical Association (CMA), the College of Family Physicians of Canada, and the Royal College of Physicians and Surgeons of Canada in the formation of the CMA task force on virtual care and the educational working group for which the content of this article was originally generated.
Authors
Kendall Ho, MD, is professor of emergency medicine in the Faculty of Medicine, University of British Columbia, Vancouver.
Ken Harris, MD, is deputy CEO and executive director, Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, Ottawa, and emeritus professor with the University of Western Ontario, London.
Toni Leamon is a patient representative in the Canadian Medical Association’s Patient Voice Group.
Author attestation: All authors contributed substantially to this article and approved the final version for publication.
Correspondence to:
This article has been peer reviewed.