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Abstract
Background One of the biggest changes to primary care triggered by the COVID-19 pandemic was the rapid integration of virtual care (VC). VC offers benefits to patients and providers but implementation presents challenges.
Methods This study is a secondary analysis of a 2021 quality improvement (QI) driven environmental scan comprising a survey and 1:1 interviews, at the Department of Family and Community Medicine at the University of Toronto. The scan aimed to understand the current and desired future use of VC at the 14 sites.
Results The survey was completed by all sites between July and October 2021 and 1:1 interviews were conducted between October and November 2021 with 12 of the 14 site/QI leads. VC was seen as convenient and flexible, and as enabling continuity of care for patients who could not easily attend in-person. Factors enabling implementation of VC included leadership at both the system and local level; a shared understanding of VC on the part of providers, patients and clinical staff; and technological and administrative readiness. Challenges included the need for triage algorithms; incongruent expectations of VC by patients and providers; technology issues; increased administrative burden; and impacts on medical education. All anticipated that some degree of VC would continue in future.
Conclusions VC offered benefits but it also impacted clinical routines and administrative processes creating new forms of work for clinicians and staff. Patient education is needed to ensure that their expectations of VC align with those of providers. Research and QI efforts are required to optimise the use of VC in primary care.
- General practice
- Health services research
- Primary care
Data availability statement
Data are available upon reasonable request. The data is available upon reasonable request by contacting the principal author. Appropriate data transfer agreements with the participating institutions may be required.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Virtual care has been shown to be effective in managing chronic conditions, improving access to care for certain groups of patients and can be a way of delivering care in the primary care setting.
WHAT THIS STUDY ADDS
This study assesses the experiences of primary care providers in using virtual care in an academic setting, as well as exploring their ideas on how virtual care can be implemented in primary care long-term and improvement opportunities that can help optimise this process.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study identifies improvement opportunities that should be explored in order to enable virtual care to be effective and sustainable in the primary care setting.
Introduction
Virtual care (VC) has been defined as ‘any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies with the aim of facilitating or maximizing the quality and effectiveness of patient care’.1 More simply, the term refers to a clinical encounter where the patient and provider are not in the same physical space at the same time. Telephone consultations and video conferencing are two common forms of VC. One obvious benefit of VC is that it enabled safe delivery of care during the COVID-19 pandemic. In addition, VC facilitates access to care by eliminating issues such as the need for childcare and the cost and burden of travel.2
Rates of VC use in Canada rose from 10% to 20% in 2019 to 60% of all healthcare visits across provider categories in April 2020, falling back to 40% of all visits in 2021.3 Throughout the pandemic, licensing requirements for physicians providing VC have continued to be determined at the provincial and territorial levels by regulatory authorities. Despite growing interest in a pan-Canadian medical license, regulatory authorities have emphasised their requirements that physicians must be licensed in their jurisdiction to offer care to patients in that jurisdiction. Fee codes for VC delivery were revised and implemented within weeks of the COVID-19 pandemic declaration and vary between provinces. Since the end of the state of emergency many provinces have amended how virtual visits are paid; for example, in Ontario most telephone visits are paid at 85% of the corresponding in-person rate except for appointments related to mental health which are paid at 95% of the corresponding in-person rate.4 Naturally, this has nudged physicians to conduct more in-person care.
VC predates the pandemic and has been seen to reduce primary care costs long-term,5 improve chronic disease management6 and enhance the efficiency of care.7 While it has proven popular with patients, more patient and provider engagement is needed.8 9 VC is also not without its challenges. Provider comfort with technology, lack of remuneration for virtual visits, security concerns and the digital divide have all been identified as potential barriers to VC.10 11
While widespread implementation of virtual primary care was propelled by the pandemic, many aspects of VC remain to be assessed. Much of the recent scholarly focus on VC has been on higher-level concerns such as rapidly changing practice patterns,12 the appropriateness of VC in different clinical scenarios,13 issues of equity and access14 15 and the need for policy responses to this evolution in primary care.16 Less well-explored is the question of how to optimise VC delivery in the medium to long-term. This will require a detailed and locally specific examination of the context and culture of different practice settings and patient populations, and patient/caregiver preferences
Methods
This study involved a secondary analysis of previously collected data from a quality improvement (QI) initiative conducted via the EXITE collaborative (Exploring Innovative Technologies in Family Medicine) at the University of Toronto’s Department of Family and Community Medicine (DFCM). In 2021, an environmental scan was conducted of the DFCM’s 14 academic sites to explore their use of VC. The scan comprised a survey of all sites (July to October 2021), and 1:1 video interviews (October to November 2021), with 12 of the 14 QI directors/VC leads. The purpose of the scan was to understand the current and desired future use of VC at the 14 sites, to gather evidence that could be used to optimise the use of VC, to identify areas of focus for research and QI and to inform the design of a future learning collaborative.
Setting
The DFCM comprises 14 academic teaching sites including both urban academic centres and large community hospitals. The 14 sites serve patients from diverse backgrounds and offer a full range of family medicine practices and specialties, including inner-city medicine, women’s health, addiction medicine and immigrant health.
There is no standardised technology or governance across the 14 academic sites. Several different electronic medical records (EMRs) are in use and, while some sites fall under hospital-based systems and regulations, others are free to choose their own technology and govern themselves.
Recruitment
Participants were selected using purposive sampling. QI directors and/or VC leads at each of the 14 DFCM sites (N=19) were contacted by email, from 1 June 2021 to 1 November 2021, to determine their willingness to participate in an online survey and one-to-one interview. Fourteen individuals representing 14 sites responded.
Participants received a link to the online survey via email, and interviews were conducted via Zoom. Zoom’s built-in recording and transcription functions were used to capture the interviews. Surveys were completed for all sites, 12 sites participated in the interview (2 sites were unable to participate due to scheduling challenges).
Data collection
Fourteen surveys were completed between July and October 2021. Questions covered the current use of VC, processes involved in booking and conducting virtual appointments, benefits and challenges of VC use and suggestions for research and QI opportunities (online supplemental appendix 1).
Supplemental material
Interviews were conducted by a family physician (SW) and a project manager at the DFCM (TO) between October and November 2021. Both researchers worked within the EXITE programme at the DFCM and came with experience in qualitative research; conducting and analysing. Although the interviewers were acquainted with participants through the DFCM, this relationship was not hierarchical in nature and the subject matter was considered low-risk enough to not affect the results. Participants were briefed on the role of the interviewer and the objective of the study prior to commencing the interview. Interviews lasted an average of 45 minutes and explored participant experience of VC including: the modalities of VC implemented at each site and the reasons they were chosen; barriers and enablers to the use of VC; processes developed to determine which type of appointment was appropriate; improvements to clinical processes such as appointment booking and use of email or other asynchronous messaging with patients; impacts on workload and workflow; impacts on medical learners; and anticipated future use of VC. The survey and interview guide were developed from the experiences of the research team and a thorough review of the literature. Please see online supplemental appendix for the full survey and interview guide (online supplemental appendices 1 and 2). Three members of the team (SW, TO and AL) would meet frequently after every two to three interviews. Through iterative adaptations, the interview guide was further refined to probe emerging ideas from participants. All interviews were recorded, transcribed verbatim and anonymised for confidentiality.
Supplemental material
Analysis
Interview transcripts were coded by LR for anticipated and emergent themes using the constant comparative method to produce a thematic analysis of findings. HyperRESEARCH V.4.5.3 was used to facilitate data management and coding. Team members met to review the coded data and supporting verbatim quotes, then identified major emerging themes from the data; informational saturation was reached.
Ethics
Ethics approval for the use of the data collected in the above-mentioned QI initiative was obtained from the research ethics board at the University of Toronto. Consent to participate in the initial environmental scan was indicated by participants choosing to respond to the email invitation. Consent to participate was reconfirmed verbally prior to the start of the interview. Consent from participants for the original environmental scan data to be used in this secondary analysis was sought via a subsequent email which asked participants to opt out if they did not consent to this use of previously collected data.
Patient and public involvement
Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research, as it was not possible to involve these groups in this secondary analysis of previously collected data.
Results
All 14 sites completed the survey component of the environmental scan and 12 of the 14 sites participated in the 1:1 interview. Participants included family physicians who were QI leads, VC/IT leads and site leads/directors.
Survey
Various modalities of VC were offered at each of the sites (table 1). Telephone care was used across all 14 sites, while secure messaging was used at 13 of the 14 sites.
Modalities of care offered across the study sites (N=14)
The proportion of care being delivered virtually ranged from 30% to 75% and most appointments scheduled by the patient were made by telephone. The process of booking appointments varied slightly across sites. All sites offered scheduling via telephone; nurses would triage the call to book the appropriate modality at six of the sites; three sites offered online booking; and email was used for booking at two of the sites. The booking process for in-person and virtual appointments was the same at 11 of the 14 sites. The remainder of the sites offered online booking only for VC appointments or had a clinical staff member assigned to booking in-person appointments.
Factors affecting the modalities of VC offered included: availability of technology (93%); patient preference (92%); comfort with technology (86%); convenience (86%); cost of technology (57%); and remuneration (43%). Participants at all 14 sites anticipated that VC would continue beyond the COVID-19 pandemic.
Many of the sites reported current or planned projects relating to VC including enhancing the efficiency of the EMR; incorporating online booking within their current booking processes; two-way email; exploring patient preferences related to VC; and optimising the triaging process while booking an appointment.
Qualitative interviews
Various themes were highlighted through the interview; short and long-term benefits of VC, enablers of VC, varied patient experience of VC, challenges of VC and impact on medical education.
Benefits of virtual care
VC was seen as beneficial to both patients and providers. Participants highlighted the convenience and flexibility of VC, especially for routine matters such as follow-up on established issues, prescription renewals, chronic disease management, completing forms and providing general health information and advice. Many participants felt that VC had the potential to improve the continuity of care for certain types of patients such as students, the elderly and those who cannot easily take time off work:
I think in some cases we may have better care … because somebody … might be willing to spend 15 minutes, sitting in their car … to talk to us … on a break … [when] they wouldn’t be able to take half a day off work and spend 20 bucks on parking to come see us … I’ve had tons of university students, who I know well, who … have to go see health services … because they can’t come see me to talk about their mood issues or their birth control … Having that continuity to contact us as opposed to having to … start with a new provider is a positive. (P6)
Some of our elderly patients, it’s difficult for them to come into the office and sometimes they don’t come in very frequently because of that. Now, you can touch base with a patient like that every month. (P16)
Enablers of virtual care
Leadership
Leadership was considered a key enabler of VC. System-level guidance, addressing medical-legal issues and appropriate use of VC had been vital during the rapid transition to VC during the pandemic. At practice level, forward-looking leadership that had been engaged with innovation prior to the pandemic was seen as ‘a huge enabler’ of VC.
Shared stakeholder understanding
Ensuring that all stakeholders had a shared understanding of VC was seen as vital to successful implementation. This required ongoing patient education and staff training:
We have to redefine what our training process is going to be and get everyone retrained. So that would be me sitting there with my admin staff and basically training them on how I want my patient flow to be handled … And then also educating my patients on what patient flow is, so … sending them out information that “This day is strictly virtual, so if you’re looking for a virtual appointment, this is going to be a good day to do it … retraining and education is probably going to be the biggest thing”. (P7)
Technological infrastructure
Sites that had previously obtained consent from patients for communication via email, or had secure communication platforms in place before the pandemic, found that they were able to make a seamless transition. Other sites struggled with the transition because of technological constraints:
If there was a way to integrate it into our EMR, I think that would improve everybody’s satisfaction … If we could directly e-mail from our charts or the conversations it would be better, but there is no way of actually doing it … We have been looking at different e-mail platforms and servers that will … integrate with our EMR so that we’re not copying /pasting and at risk of having an incomplete chart. (P9)
Sites whose IT was governed by a hospital were especially challenged because their ability to adapt was limited by the larger system:
We’re not able to implement it because of how our system is entrenched under the [hospital] system … any sort of decision we make has to also go to the hospital so that adds … a barrier … in terms of time and going through hoops … to implement stuff. (P15)
Patient experience of virtual care
Participants reported that patients generally appreciated the convenience of VC, especially for straightforward matters such as test results or routine chronic disease management. For some, who were homebound or had mobility issues, VC provided a valuable alternative to in-person care. Overall, many patients preferred telephone appointments to video calls because they were simpler to arrange and less prone to technical difficulties.
Participants also noted that VC was not popular with all patients, especially older adults:
There is a component of our population, let’s say 65 and over, who may not even perceive a telephone call as care, … that may not feel like they’re being cared for in the way that they’re used to being cared for. Fifty and under I think love it … they are not keen to come into the office, they’re happy to communicate by email. (P8)
The only challenge with the telephone and virtual care that we’re learning is that it’s not for everyone … some people really felt excluded … people felt uncomfortable with talking on the phone. They wanted to just come into the office … I think that there were people that felt as though the system wasn’t working for them or giving them what they needed. (P11)
Challenges of virtual care
Despite its many benefits, VC also presented numerous challenges beyond the ubiquitous technical difficulties with video conferencing and consent and privacy issues.
Increased administrative burden
Many participants found that the transition to VC had increased the administrative burden for both providers and clinical staff as existing systems had to be retrofitted to new ways of working:
The person who comes in first thing in the morning is charged with transferring all the appointments that have been booked online into the EMR, and at the same time doing a bit of a triage if needed. (P7)
Challenges arising from use of email and secure messaging
The use of email and secure messaging was highly variable both across and within sites giving rise to a plethora of unanticipated challenges. Providers often had more than one email option sometimes leading to variations in practice between colleagues within a single site. This created a need for protocols to determine the most appropriate communication channel in a given circumstance as well as requiring manual transfer of all email correspondence to patient charts if the email was not embedded in the EMR. Some practices had an additional administrative email address that patients could use to send in forms or photos (e.g. of a rash). This became more correspondence that would have to be manually added to the patient’s chart. Email also required a patient registration process and the development of carefully worded disclaimers alerting patients to the dangers of using email for urgent medical concerns; there were examples of emails from patients going to junk mail. In certain practices, email communication had to be provider-initiated and controlled while in others it did not. In other words, as this participant explains, using email to communicate with patients created a whole new layer of administrative activity:
It’s created a completely different workflow … you have this whole other platform where patients are trying to contact you and ask you medical questions … and then going back and forth on email is not appropriate … we don’t always look at our email. Most of our email is for administrative duties, so that might be missed, and then it adds another workflow in terms of us copying, pasting and adding it to the EMR. (P15)
Secure messaging through a patient portal created its own set of challenges as it gave rise to an unmanageable volume of correspondence from patients at certain sites:
The system allows patients to directly message and people just found that overwhelming …We tried having admin and nursing staff screen the messages for a while … In the second month I think … for the ten of us … we had 3000 messages. (P16)
Booking appropriate type of visit
One of the most complex and widely shared challenges was ensuring that care was delivered using the appropriate modality as some health issues were not suited to virtual encounters. This gave rise to the need for an effective triage system which, in turn, necessitated changes to appointment booking systems, staff training and the development of algorithms to guide administrative staff:
The challenge is … a very clear algorithm that we could create for the admin staff … We don’t want our admin staff to be making clinical decisions … You could have a 50-year-old who’s got hypertension who says, “I want a virtual appointment,” but … they haven’t been in in a year, they don’t have a home BP cuff, there’s all sorts of variables. So, it’s really tricky to make an algorithm that’s going to be clear cut. (P6)
Divergent expectations of virtual care
Participants noticed that patients were often unprepared for virtual appointments because they did not perceive them as having the same status as in-person visits. Patients might not have all relevant information on hand or be in an appropriately private or quiet location for a telephone appointment:
Patients know, when they come to your office … they have a limited time because there’s someone else waiting … I’m not sure patients always perceive it in the same way as “I have to go to the office, and I have to make time.” So, oftentimes I get “I’m just in the middle of something, can you call me back?” … If I could see something coming out of this discussion, it’s education around what is virtual care … and what are the things that we can do together as patient and physician to make it a more fruitful endeavour. (P8)
Participants also noticed an increase in patients reaching out because it was easy to do rather than because they had a substantive medical concern:
People have a thought in their mind and call me … like …“Have you taken a Tylenol?” “No, I just thought I’d call you.” … Really, the standard of calling me is so low, I can be on the phone forever. (P13)
Most concerningly, because practices were trying to respect patient preferences, requests for virtual visits frequently resulted in duplicate appointments when the issue turned out to be one that required an in-person visit.
Impacts of virtual care on medical education
Medical learners were heavily impacted by the pandemic as interactions with patients were overwhelmingly weighted toward virtual visits. Participants noted that, while residents had ample opportunity to hone their history-taking skills, they had little opportunity to engage with patients face-to-face. As a result, their examination and procedural skills and rapport with patients were noticeably lagging:
They were just on the phones, so they have great triaging, have great history. But when it comes to the actual examination of the patient … we have to do a lot more teaching in terms of physical exam skills. And we are also noticing … it is a little bit more intimidating to actually speak to a patient face to face as opposed to being on the phone with them. (P9)
We haven’t done our OB [obstetric] half day in two years. They haven’t learned to do endo biopsies they haven’t learned to do perinatal repair… punch biopsies … lesion removals, they haven’t learned those hands-on things. (P8)
The shift to VC also made it more difficult to supervise several learners at once in teaching clinics and to provide feedback to medical learners in a sensitive manner. One participant noted that they were getting, ‘negative feedback [from medical learners] … pretty much across the board’. (P16)
Discussion
The environmental scan found that VC offered benefits to both patients and providers. Many participants hoped and expected that VC would become a permanent part of primary care. In addition to enabling care delivery during the pandemic, it offered a flexible and convenient option for dealing with routine matters not requiring a physical examination and enhanced access and continuity of care for some patients. Participants felt that many patients seemed to welcome VC though they noted it was not a good fit for some older adults and patients marginalised by the digital divide. In-person appointments may also be more suitable during the initial phase of the patient–physician relationship to foster a deeper level of trust and familiarity with each other.
VC also presented challenges. Participants described widespread increases in administrative burden for both staff and clinicians, misaligned patient and provider expectations of VC, increased complexity of appointment booking, duplication of appointments and substantial impacts on medical learners.
This study provides insights into the practical challenges of optimising VC as it becomes a more permanent feature of the primary care landscape. What is clear is that there is nothing simple about the shift from in-person to VC and there can be no ‘one-size-fits-all’ solution. Video, telephone and email are neither interchangeable nor equally well-suited to all forms of consultation; each has its own booking and technical requirements and provider comfort with different technologies varies as does their diagnostic capability in different virtual situations. EMR platforms can either enable or impede VC depending on their configuration, flexibility and established practice processes. Implementation of VC creates new workflows for providers, and the need for process change, staff training and ongoing patient education. Complex triage algorithms are needed to ensure that VC is used in a clinically appropriate manner while respecting patient preferences which will, themselves, be highly variable, as will patient access to, expectations of and willingness to engage with VC. As opportunities for medical learners to engage with patients become virtual, there are questions about how the next generation of family physicians will hone their physical examination and interpersonal skills. Finally, and perhaps most importantly, there are health equity implications associated with the shift to VC that extend far beyond either the physical or virtual consulting room.17
Conclusion
As the experiences of participants in this exercise clearly demonstrate, VC is not simply a technological translation of conventional care. This points to the need for a highly context-sensitive approach to the implementation of VC, something that policymakers must understand as they develop funding structures and regulatory frameworks for the longer-term. It also highlights the importance of meaningfully involving administrative staff and patients in the design of VC as roles shift and patterns of engagement between providers and patients evolve.
Process-focused approaches to VC are beginning to emerge.18 19 While the challenge of VC may seem daunting, it is also an unprecedented opportunity for providers, staff and patients to build on these examples and collaborate in shaping the future of primary care.
Data availability statement
Data are available upon reasonable request. The data is available upon reasonable request by contacting the principal author. Appropriate data transfer agreements with the participating institutions may be required.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by University of Toronto Research Ethics Board Protocol #43399. Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors The study was conceptualised by SW, with support from PO, AL, OB and LR. The conducting of interviews and qualitative transcript analysis was completed by all authors. SW prepared the first draft of the manuscript. All authors participated in editing the final draft and approved the final manuscript. SW is the guarantor.
Funding This work was supported by Healthcare Excellence Canada.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.