The future of virtual care is in relationships

Note: this article was originally published in Healthy Debate on Nov 23, 2020 by Dr. Dominik Nowak and was translated from English to French. 

I will never forget Emily, a 23-year-old patient in my family practice. We would talk about issues like immunizations, cancer screening and contraception. Then came one tragic summer morning. A car collided with Emily’s bike. She survived the accident but needed surgery for a broken leg. 

Several weeks later, we were working on her recovery. Emily had a tough time moving so we met virtually. “I feel tired, but I’m sure it’s the pain pills,” she said one day, feeling exhausted and a little short of breath within minutes of starting her exercises.

The virtual visit meant that I could not examine all of Emily’s vital signs or her heart and lungs. Yet, I could see her on my screen and I remembered how she looked when healthy. She showed me the high heart rate on her smart watch. She sounded anxious and her face was flushed. My intuition, formed over years of visits with Emily, told me something was wrong. I told her I was worried and that she should go to the hospital. 

Emily was reluctant but trusted me. The doctor at the hospital diagnosed her with a pulmonary embolism, a blood clot in her lungs that may have ended her life were it not for timely treatment. Virtual care allowed Emily the visit but continuity of care saved her life.

Access and continuity saved Emily’s life.

Virtual care promises access to people seeking care, wherever they need it. For Emily, the combination of access and continuity made the difference. Continuity of care involves seeing the same person or team for care over time. In caring for our health, continuity of care brings more than comfort and confidence – it adds quality to care and years to life. At a time when many are seeking care virtually, continuity is as important as ever.

Millions of Canadians have neither access nor continuity.

Many like Emily benefit from continuity of care but more than a million Ontarians do not have a family doctor or primary care professional. Across Canada, virtual offerings continue to scale rapidly to temporarily meet this need. Like regular walk-in clinics, they form an important safety net and help many people access care. Similar to regular walk-in clinics, however, virtual walk-in clinics often lack any form of continuity with the rest of the healthcare system. For Emily, it would have meant seeing a stranger, with no understanding of her story, health or values and no way to connect that care to her family doctor. 

Virtual walk-in clinics have a place but they must be in a broader system that promotes continuity of care.

Virtual care can promote continuity from a dedicated clinician.

Unlike in-person care, virtual care has the benefit of being accessible regardless of place, meaning Emily and I could meet despite her broken leg. In my practice, the virtual option allows both access and continuity to many who find it difficult to meet in-person or during office hours – working parents, young families, older adults whose caregivers join the visit. Virtual care lets Emily and others like her receive the right care, for the right problem, at the right time, by the right person. By removing barriers around transportation, virtual care can promote continuity with a dedicated health professional.

Virtual care can promote continuity from a dedicated team.

Although continuity with one clinician has benefits, it is not always realistic. No matter how dedicated, one family doctor cannot be available at all times and in all contexts. Continuity from a dedicated team is more practical. For a team, virtual care can bring the connectedness that health professionals need to thoughtfully collaborate. 

Imagine if we all had a team of experts to manage and coordinate our care who may not always be co-located but could nonetheless work together through technology. I could connect with Emily’s surgeon, physiotherapist and pharmacist, track her progress, dose her pain medications and work with them on her health. Through technology, we could collaborate as if we were in the same office. By removing the location barrier, virtual care can promote continuity from a dedicated interdisciplinary team.

Virtual care can promote continuity of data.

Sometimes, people need urgent care from clinicians outside of their dedicated team. When this need arises, the onus should not be on patients or caregivers to repeat traumatic stories or to compile tomes of health information for the visit. If Emily needs to see a doctor from another office, we must create a system in which this new doctor can see Emily’s medical records, recent lab results and general goals of care. After the visit, we must make it easy for clinicians to connect that episode of care to the person’s dedicated care team. As a minimal standard, virtual care must promote continuity of data.

Continuity is a matter of equity.

Discontinuous care should not be the only option for people without a family doctor or primary care professional. People without some form of continuity often receive fragmented care by multiple professionals and no longitudinal health guidance. 

In the Hamilton Spectator’s Code Red series, investigators found that the neighbourhoods with the fewest residents connected to a family doctor were also the ones with the most emergency visits for mental health crisis, highest rates of poverty and the worst maternal health outcomes. Virtual care’s adoption curve risks widening this chasm. 

Many Canadians also will face the digital determinants of health, lacking internet access, proficiency with technology, a safe space to have personal conversations and a caregiver to help with their visit, not to mention other structural barriers. 

For many people, there is a difference in the care they might receive while in a shared living room, away from the privacy and safety of their doctor’s office. Emily, for example, lives with her parents and is more comfortable discussing mental health or sensitive issues in-person or from the park. Accessible virtual care does not replace the need for continuous virtual and in-person primary care. Despite virtual care’s rapid adoption, we cannot leave any Canadian behind from high-quality primary care.

The evidence is clear: healthy primary care policy creates healthy communities. For people like Emily, virtual visits with her family doctor’s office promote access and continuity. Every Canadian deserves the kind and careful care made possible by continuity in all its forms. Especially for the millions of Canadians without a family doctor, our provincial ministries of health must ensure a system in which every Canadian has virtual and in-person care grounded in a continuous medical home. 

With the promise of technology, it is beyond time that we cement continuity as a core value for the care of all Canadians, in all contexts, with all clinicians.

Dr. Dominik Alex Nowak, MD MHSc CCFP, is a family physician, physician lead of the TELUS MAC, health systems strategist and faculty member at the University of Toronto.