Virtual care has been part of Dr. Jonathan Fitzsimon’s practice from the moment he became a family doctor in 2007.
Serving the rural community of Arnprior — 65 kilometres west of downtown Ottawa — Fitzsimon knew that not everyone could take off work or travel long distances and visit his office in person.
“For a long time, I used telephone calls to update people on results that perhaps didn’t need any particular immediate action,” he said. It worked for his practice in particular, because Fitzsimon is paid a salary based on the number of patients he has, rather than having to bill Ontario for his services, where there are no permanent billing codes for virtual care.
For doctors like Fitzsimon, virtual means of connecting with patients were always a part of a family physician’s arsenal in the 21st century. But as the COVID-19 pandemic accelerated the adoption of virtual care in response to stay-at-home orders, many are asking: Are virtual means of connecting with our family physicians here to stay? If so, at what capacity? And will the standard of care still be met?
It’s a question family doctors across Canada are still trying to answer as they deal with a growing backlog of patients trying to access care, amid a pandemic that remains unpredictable — COVID-19 cases are rising again in Ontario and a new variant of concern, Omicron, has led to the reimposition of some travel restrictions.
But with the majority of Canadians vaccinated, provinces are urging doctors to move away from virtual care wherever possible and to start seeing more patients in person. In Ontario, Dr. Kieran Moore, the chief medical officer of health, issued a joint statement with the province’s regulatory college for physicians and surgeons on Oct. 14, asking doctors to see patients physically after a growing number of reports that some aren’t providing in-person care.
At the Children’s Hospital of Eastern Ontario, virtual visits to the emergency department were suspended Dec. 1 due to a rise in demand for in-person care. Elsewhere in Canada, Manitoba has issued the most decisive directive yet, with its College of Physicians and Surgeons saying that as of Nov. 1, “it is not an acceptable standard of care to solely practice virtual medicine.”
Provincial data shows the average of in-person medical visits throughout the pandemic hovered at 50 per cent, increasing to 58 per cent in August as vaccinations ramped up. That rate is expected to grow.
Earlier in the pandemic, virtual codes were implemented temporarily in Ontario to help doctors get paid for doing work remotely — most doctors must bill the province per service they provide — but the Ontario Medical Association asked for the billing codes to remain in place permanently. That was not granted. Instead, the province extended the codes to September, 2022.
The OMA and Ontario are engaged in another round of negotiations for a new Physicians Services Agreement as of November, though neither would say whether permanent virtual billing codes are once again on the table, citing confidentiality.
For family doctors in Ontario, a permanent move toward virtual care would be welcome, but it comes with some asterisks.
Dr. Jennifer Kwan, a family doctor in Burlington, said that before COVID, she would sometimes call her more senior patients who wouldn’t be able to come in to discuss blood work results. With no way to easily bill, she chalked it up as volunteer work.
“I think it would be taking a step backwards to remove (virtual care) for patients,” Kwan said. “It’s a good option when it’s used appropriately for accessibility and convenience.”
But Kwan said it’s important virtual care is used without compromising standards, a view in line with guidance issued by regulatory colleges nationwide.
Doctors who spoke to the Star said they view virtual care as a good followup tool with patients that can remain beyond the pandemic. But things like Pap tests, measuring blood pressure or routine checkups for newborns have to be in person, said Dr. Elizabeth Muggah, a family doctor in Ottawa and president of the Ontario College of Family Physicians.
In the Manitoba directive, virtual care is seen as a good option if patients in rural or remote areas can’t be seen in a timely manner. But the college says in-person assessments are necessary most of the time to truly meet the standard of care, and that family doctors should refrain from referring a patient to a specialist without first seeing them in person.
Throughout the pandemic, Muggah said she’s offered her patients the option of both in-person and virtual care, depending on their level of comfort. But she added she’s pushed to see patients in-person when a physical checkup is warranted. As of November, Muggah said about only half of the visits at her practice were in person, less than the provincial average. While she is offering in-person slots, she said many patients aren’t taking them.
“It’s really clear that patients have embraced the use of virtual technology and like having that as an option,” she said. Muggah added that some of her patients are from outside Ottawa due to an overall persistent shortage of family doctors in Canada; 14.5 per cent of Canadians ages 12 and up don’t have one, according to the latest data by Statistics Canada.
For those who did access virtual care in the pandemic, it was both a hit and a miss. Aaron Chen, who lives in Toronto, said he made appointments with his family doctor regularly in the last 18 months for a chronic skin condition. Many of them were by phone — a good way to connect for minor consultations, he said, but with some challenges.
“Sometimes I felt like I had to explain a lot more, because he couldn’t see what was happening,” Chen said, especially when he had a skin rash. “Sometimes, I felt like I was diagnosing myself.”
When words failed, Chen would send photos or go on video so his doctor could better see his symptoms, but he worried about privacy issues around electronically sending pictures of his body. He added his doctor now offers most appointments in person, which he prefers. “The secure feeling of having an appointment in person is so much better,” he said. “(My doctor) can actually see what’s happening.”
Dr. Tara Kiran, a Toronto-based family doctor, looked at how thousands of patients in the city feel about virtual care. In a survey of more than 7,000 patients in the city, more than 90 per cent said they were comfortable receiving care by phone, email or video. But those who weren’t were primarily lowincome, with poorer health, and came to Canada in the last 10 years.
In the findings, Kiran said healthcare providers need to consider how to best incorporate virtual care in their practice to ensure equity of access.
“I don’t think that stand-alone virtual care can meet the standard of care,” Kiran said. She added she hopes the College of Surgeons and Physicians of Ontario (CPSO) will take its cue from Manitoba’s clear directive.
Fitzsimon, the rural physician, is more critical of Manitoba’s directive, arguing it misses the mark on how virtual means of connecting could help transform primary care in the country.
A functioning primary-care system, Fitzsimon said, is one that understands that in-person care is sometimes better provided by other health professionals, like specialists or therapists, while collaborating with a family doctor who acts as a navigator and medical lead for their patient. This collaboration can be done virtually, he added.
“That (model) fits beautifully for using these new virtual tools,” he said.
Shae Greenfield, a CPSO spokesperson, said the college is still in consultations about its policy. Its current guidance does not specify the circumstances where virtual care would be appropriate, citing patients’ unique needs as the reason for flexibility.
“The policy indicates that in most cases, a virtual-only approach would not be considered acceptable, but recognizes that there are a wide range of situations and allows room for some exceptions,” Greenfield said in an email.
He added if patients are being refused in-person care or if standards are not being met, they should discuss these concerns with their doctor or file a complaint with the College. Since August, Greenfield said the College has received 70 calls from patients about inability to access in-person services, though not all amount to formal complaints.
While the OMA won’t comment on whether it will be pushing the province to include permanent billing codes for virtual care, its president, Dr. Adam Kassam, said the pandemic has led to an evolution in how health care is provided, and the extent of that evolution is still being determined by all physicians.
“I like to think about (virtual care) like a medication — there’s an appropriate dose,” Kassam said. “There is a specific type of intensity, or frequency or duration and a specific type of patient population where this is appropriate.”
Pre-pandemic, doctors in Ontario offering any virtual services could bill through the Ontario Telemedicine Network — a government agency that’s part of Ontario Health, offering its own secure video conferencing platform — and much of its programming operated on a pilot basis.
However, doctors can’t bill for telemedicine services outside the services available by the network, hence virtual billing codes were introduced temporarily in the province due to COVID-19.
By contrast, British Columbia has a much more liberal approach to telemedicine. Doctors there have been able to bill the province’s OHIP equivalent with a variety of telehealth codes since 2011 for any medical visit not requiring a physical exam.
It’s unknown whether the pandemic’s impact will force Ontario to follow suit. As of publication, the OMA said there is no timeline on when its negotiations with the province will conclude.
But doctors — and some patients — hope progress gained during the pandemic will not be lost.
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It’s really clear that patients have embraced the use of virtual technology and like having that as an option.
DR. ELIZABETH MUGGAH FAMILY DOCTOR