Posted on June 22, 2016 by Dr. Rashaad Bhyat
A physician colleague of mine recently reflected on the changing nature of his practice, in the years since he started using an electronic medical record (EMR). He noted that an increasing amount of his work as a primary care physician does not actually require the patient to be in his office.
He lamented the fact that his patients often journeyed to his clinic for a fairly straightforward review of their results (labs, for example) — discussions that might otherwise have taken place in a more efficient manner, perhaps virtually.
Thus we arrived at the subject of e-visits.
E-visits can be defined as a “secure, two-way digital communication between health providers and their patients that can include emails, text messaging and video conferencing,” 1and overlap with the concepts of telemedicine, telehealth, and virtual care.
A gap exists between patients’ interest in services like e-visits, and clinicians’ current use of these modalities, as noted in this article by Jennifer Zelmer and Simon Hagens.
Emailing one’s physician, for example, is a more complex issue than one might imagine, as outlined in this article by Rayar et al. In a Commonwealth Fund Study from 2013, only 11 per cent of Canadian physicians were using email to communicate with their patients. Meanwhile, about 20 per cent of family physicians report use of telehealth or telemedicine technologies in their offices based on National Physician Survey (NPS) 2014 data, indicating the widespread adoption of virtual visit technology is taking hold slowly.
Increasingly, generations of Canadians favour text, instant messaging, and video (e.g. Skype or Facetime) as a means of communicating. In their minds, phone, fax and even email may seem quaint and dated.
So, what is holding things up? It is not for a lack of technology, which clearly exists. Canadian organizations in both the public and private sectors have shown this to be feasible, and the Ontario Telemedicine Network is just one example. You can find other examples here. One large provider in the U.S. estimates by 2018, their healthcare group will have more virtual visits than office visits.
One challenge is that clinicians may struggle to reorganize and re-imagine their workflow around these new technologies, while simultaneously ensuring safe and effective patient care, with attention to privacy and security concerns. However, often, the bigger challenge lies in physician practice and remuneration models that have evolved relatively slowly, making it difficult for interested doctors to implement certain technologies even if they want to. A recent CIHI report estimates in Canada, for example, about 70 per cent of physicians are paid through a fee-for-service model (i.e. they are paid per patient or procedure).
According to the NPS, 80 per cent of family physicians are not compensated for email consultations with their patients. When appropriate mechanisms for recognizing the value of new forms of communication do not exist, many clinics struggle to implement them.
Another challenge may relate to misconceptions around how patients feel about virtual care. Consider this recent study on virtual visits, which provides some clarity on this matter. The study found that 93 per cent of patients who had a virtual visit said it provided high quality care. Another 98 per cent agreed that virtual visits were easy to use and saved them time. In the same study, ninety-one per cent of patients say their most recent virtual visit performed well in meeting their health care need or issue at the time.
Despite these hurdles, innovative clinic groups have forged ahead with e-visits and some elements of virtual care. Some clinic groups have implemented secure messaging communications, using solutions that integrate with their EMR system. Meanwhile, other clinic groups are pushing the envelope even further with completely virtual care models.
We live in a time of immense, rapid change within healthcare and medicine in particular. In the next few years, as patient care continues to move from large institutions into the community and patient’s home, the standard clinical encounter will evolve. The concepts of e-visits and virtual care, supported by appropriate policy changes, will play an increasingly important role. The office visit as we know it, may never be the same. What are your experiences with, and thoughts about e-visits?
Have a comment about this post? We’d love to hear from you.
Dr. Rashaad Bhyat is Clinician Leader, ACCESS Health at Canada Health Infoway. He is a family physician with a special interest in Digital Health. He currently practices in an EMR-enabled family practice in the Greater Toronto Area.