Given the COVID-19 crisis, many organizations have been abruptly pulled into the world of telehealth and the broader world of virtual care before they were fully 
prepared. Sounds familiar doesn’t it? You may recall go-lives and how you needed to “just get it live” and worry about optimizing later. This is even more true right now with telehealth. There are many opportunities to optimize and fully harness the power of virtual care. It’s so much more than just the technology that enables the encounter.
To explain how we might finish what we started with virtual care, we sat down with Dr. Laura Copeland, who is both chief medical information officer at Healthtech Consultants (a Nordic subsidiary) and a practicing physician. We talked about how her private practice has changed and what changes she still sees necessary to make virtual care truly deliver on its promise.
Enjoy the conversation and if you have questions, remember to write us at AskHealthtech@healthtech.ca. Thanks for listening!
Show Notes
[00:00] Intros
[02:26] Dr. Copeland’s experience with virtual care to date
[04:53] Main challenges that need to be addressed in virtual care
[06:00] Improving the patient user experience
[08:25] Improving the provider user experience
[12:12] Policies slowing down virtual care
[14:30] The “fluidity of experience” and the challenges that creates
[18:30] The evolution of care access
[19:55] Summary of actions needed to move virtual care forward post COVID-19
[21:10] The future of virtual care
Transcript
John Pollard: Hello everyone and welcome. I'm John Pollard, part of Nordic's podcast team. Today we're going to have a conversation about virtual care. Many of you in healthcare have propelled virtual care to the forefront in the wake of COVID-19, but according to my guest today, Dr. Laura Copeland, there's still plenty to do. Dr. Copeland, welcome.
Dr. Laura Copeland: Thanks, John. I'm happy to be here today.
John Pollard: Before we get started, give us a little bit about your history, and how you got into this crazy world of health IT.
Dr. Laura Copeland: I started my career as an emergency physician. Then shortly after beginning, I found myself in a health information system implementation at the Cleveland Clinic, and that launched an entirely new career for me. I found myself at Humber River Hospital next for about 10 years, helping them transform their hospital from mostly paper to a completely digital hospital.
And then since then I've joined Healthtech so that I can wander around Canada, helping other organizations bring up health information systems, and making sure that their physicians are happy and have a sense of shared ownership with their system. That's what I do most of the time. I also still have a practice where I see patients for medical psychotherapy.
John Pollard: So to date then, as we talk about virtual care, what has been your experience with virtual care?
Dr. Laura Copeland: Well, I think I started getting really excited about virtual care when I was at Humber, and we began planning some of our next phases, which involved heavily including virtual care. I found myself working with information system vendors to help develop workflow within their product to initiate virtual visits.
Dr. Laura Copeland: In the midst of all that, the Health Standards Organization in Canada was looking for somebody to sit on their technical committee for technology-enabled healthcare. They invited me onto the committee with patients, and policy makers, and other providers, and organizations to talk about what we called telehealth at that time. When we actually published the recommendations, we titled it virtual care because we thought that better reflected our future. So, that was the beginning from an administrative type of perspective, but I was very excited to start using it in my clinical practice as well.
I guess about two years ago, I was invited to be part of a pilot study here in Ontario with the Ontario Telemedicine Network. A few physicians were selected to be able to start seeing patients in their homes and provide therapy within their homes. So, I started seeing patients.
I guess I had the expectation that I'd have a really rapidly growing practice because who wants to spend an hour commuting to your therapist's office, and then an hour sitting in the office, and then an hour going home. I thought people would want to be able to connect from their own home or from work, but really this is not what materialized in my practice at the time. I settled into a steady state of about 20% of my practice being virtual care, and the other 80% of the patients still chose to, for the most part, come into the practice, or they simply couldn't navigate the virtual care platform in order to have the satisfactory visit with me.
That's where I was prior to COVID. Then I think, along with everybody else in maybe even the world, we launched into really 100% of all visits being virtual because there was simply no other option to keep everyone safe.
John Pollard: So like you said, now you're 100%, given the COVID-19 pandemic. We're here, the genie is out of the bottle, so to speak, with virtual care. But you think that there are still some challenges that we need to address. Tell me more.
Dr. Laura Copeland: Well, goodness, if that genie is out of the bottle, yeah, I could think of three wishes that I would have for the genie. Probably the first wish is that we could improve upon the user experience, and that involves both patients and provider experience.
Secondly, I think we have some work to do in looking at our policies and procedures, and making sure that they fit our new reality so people aren't confused by them.
Then I think we need to consider what this does to the quality of care and making appropriate decisions about the level of care for our patients, and finding new quality metrics to make sure that we're doing the right thing.
John Pollard: Excellent. Okay, well let's break those down one by one. So first, you see opportunity for improving the patient user experience. What are the challenges specific to that patient user experience?
Dr. Laura Copeland: Well, some patients, they can pop on to a virtual visit the first time you send them an email saying, "Hey, here's the opportunity," without any problem whatsoever. I would say that's probably about 20-30% of the patients. Then you have your group of patients who need a little extra IT tech support. It might be they need better bandwidth, so it's more of an infrastructure issue within their own homes. That's difficult to deal with because we can't suddenly improve their quality of their network or their bandwidth, so that's in many ways a no starter.
But there are a lot of patients who just need some guidance in what buttons to push, or how to set their microphones so that their headset is picking up the sound instead of their computer. These things can be done by appropriate supports.
It's interesting during this COVID crisis, our administrative staff has really stepped up to the plate to offer a lot of this support. As we've onboarded more and more patients, who initially hadn't been very comfortable with virtual care, they've been able to get on the phone and walk them through. Push this button and push that button. I have to say, I really admire that they've stepped up to the plate here because it is not at all within their scope of work, nor was it in their skill set, so they had to do a lot of learning.
But we're going to need to continue that as we go forward. We need to continue to have people on the line that patients can reach out to, to walk them through getting their video visit launched. We're going to have to change some job descriptions in order to do that, I think.
John Pollard: Are you suggesting that there may be new roles necessary in this new land of virtual care then?
Dr. Laura Copeland: Either new roles or expanded current roles.
John Pollard: Well then on the provider side, let's talk about that experience and what sort of experience improvements might you be lobbying for?
Dr. Laura Copeland: Well, I think one of the things that I've struggled with way before this COVID experience, and continue to struggle with, and actually hear a lot of my colleagues complaining about as well, is the challenge of coordinating calendars, schedules. It seems like a fairly simple thing, but if you have three calendars on the go, and you have to check each and every one of them to make sure that you can actually schedule a patient visit, it's challenging, and it can lead to mistakes, which I don't feel is very professional.
I'll give you some examples. So, in order for me to schedule a patient, I have to go into OTN and schedule the virtual visit in my virtual care platform. Then I have to go into my EMR and schedule the patient encounter in my EMR so that my administrative assistant doesn't schedule somebody else in that timeframe. And so I have an encounter I can actually document against when that patient is having their appointment. Then I have to go to my personal calendar and make sure that if it's not a time that I've already blocked off for patient care, that I've blocked it off on my personal calendar, so my family doesn't try to schedule something.
It's complicated. It would be really wonderful if our EMRs or health information systems could include in the scheduling, the scheduling of the virtual care appointment as well. So, having that kind of integration would be great. I'm going to go on, John, because you've touched on a topic that I love.
It's not just about the workflow though. It's also about having systems that can work reliably. Because there's nothing more frustrating than being in the middle of a patient visit and having it suddenly drop. Right now, this is one of our biggest challenges. Because even those platforms that were stable prior to COVID are now being challenged by the mere bulk that we're seeing at OTN. I think that our visits increased by tenfold in the course of two weeks.
Then you get crazy workarounds because doctors are calling their patients on the telephone in order to keep a voice conversation going. And then logging onto OTN, so that they get a visual whenever they possibly can. Because when we see our patients, we gain a lot more information about what might be going on with them. We can see their color, we can see their animation. It's actually kind of helpful to see their lives around them in the room too. A lot of information can be gathered that way.
John Pollard: Right. It is amazing how complicated scheduling can be with all those systems.
[Commercial break]
John Pollard: Obviously you mentioned some more challenges though around the areas of policy and procedure. Let's talk about some of those policies that maybe have been slowing down the spread of more widespread virtual care.
Dr. Laura Copeland: Well, I think that the first that comes to mind is the most obvious and that's reimbursement. Here in Ontario, if I had not been part of the pilot project for reimbursement to see patients in their own home, I could not have, I simply would not have been reimbursed for it. So, when you're not being paid for a service, you're probably not likely to do it. So, that's a bit of a no brainer.
Now we have a bunch of temporary billing codes. Some of these codes are so temporary that they haven't even managed to code them into the billing system. So, there's some changes that need to happen for our billing systems to evolve to even accept billing of new procedures like virtual care or telephone medicine. So, that's probably the first thing.
But there are a lot of other things that have confused providers for a long time or put them in awkward situations. For example, I am licensed in Ontario to practice medicine, and I am paid to see patients who are in Ontario. So what happens when my patient goes on vacation and still calls in for their therapy appointment? And I'm sitting there looking at the Palm trees in the background going, "Gosh, I don't know of any Palm trees in Toronto, but maybe I won't mention that right now because it's kind of confusing, muddy water there."
When you can suddenly access care, never mind where you are, so long as you have a good connection, then what does that do to our licensing and a lot of the way we pay providers? I think we have to consider if there needs to be some changes in policies and procedures in order to address our new reality.
John Pollard: Right, and we have those same problems here in the U.S. between states and how people are licensed and such as well. It's definitely a challenge that needs to be addressed. So, in some of your writings about challenges, which I've had the privilege to look through recently, and you're talking about virtual environments, you mentioned the “fluidity of experience,” and I'll use my air quotes there. What do you mean by that and why is that a challenge?
Dr. Laura Copeland: Oh, OK, a patient can these days start with an encounter with our healthcare system using something like a chatbot. In general, we don't charge or bill for chatbot experiences, but at some point then the patient might be directed to a telephone encounter. So, there is something that's potentially billable. You're talking to a provider of some sort over the telephone.
Then the provider decides, "Well, this isn't really adequate either. I think I want to actually visually see this patient." So then you move to a virtual visit, which by the way might have a different billing code, just to be confusing. Then at that point you say, "Well actually, I really need to do a physical exam. I think I need to see you in the office." Then you have an office visit, which might be scheduled for the same day.
So, how are we billing this? Are we taking the most involved engaged experience? So in this particular scenario, like an office visit, and we're saying, "Okay, you can only bill for the office visit." But what about that journey? Is the bill for the office visit really reflecting all of the work, and coordination, and infrastructure required in order to have brought the patient through that journey?
And that journey is a useful journey for our healthcare system because it helps with efficiency and capacity planning. Why do you need everybody to come into the office when so many of these cases can be dealt with on the telephone? So, isn't it wonderful to have the system in place that allows you to do that? So it's complicated, the fluidity of care challenges from a policy and procedure perspective, but it also produces some challenges from a level of care perspective.
I gave you a scenario where you had a physician who was being very cautious about, "Do I have enough information? Maybe I should increase the information I have before I proceed to a diagnosis and treatment." But what if you have a very busy distracted provider, who may be overwhelmed, and they make some assumptions based on a level of care that perhaps wasn't appropriate for that patient? Not seeing the patient, you don't know that they're turning blue, but you know, hey, it was a telephone visit. So, how do we police ourselves as physicians, and make sure that we're providing the level of care that's appropriate for the particular diagnosis?
John Pollard: Right. Yeah, you lost me there for a bit when you said that there was an example of a provider that might be overwhelmed. I don't understand that.
Dr. Laura Copeland: Well, it's funny because we all think that providers are overwhelmed right now. I would say there are certainly some working in areas where we're seeing the pandemic hit very hard that are definitely overwhelmed. At the same time, you have a lot of doctors sitting around being kind of frustrated because nobody's coming into the clinic because they're afraid to come in and expose themselves to the virus, or maybe expose somebody else to something that might be going on with them. So, we're kind of seeing ghost town clinics. Then all of our surgeons are kind of on vacation in their homes right now because elective surgeries have been canceled. So, some not so overwhelmed right now.
John Pollard: Yeah, and I was joking clearly, but it is a frustrating time to be in healthcare. I mean, we know that that is for sure the truth. So, all of this, all of what we're going through is ultimately going to change how we look at care. Tell us how you see care access evolving as a result of all of this.
Dr. Laura Copeland: Well, I can tell you what I hope for. I'm being very careful here to say this is my desire, as opposed to predicting the future. Because I think one of the things we've learned out of this COVID pandemic is that despite our wonderful data, we're not fantastic at predicting exactly what's going to happen next.
What I would love to see happen is I would love to see access not be an issue. If you're in a remote community, I think you should still be able to receive the specialty care that's available because you can call in remotely. I think that would be great. I also think it'd be wonderful simply for society as a whole to not have the burden of time spent going to the doctor's office, and the commute, and the emissions from your commute in order to get places that you don't necessarily have to go.
I think that maybe we'll learn quite a few positive things from staying at home. That is we really don't have to go out all the time, or travel places, and we can be far more efficient and safe as a society if we are judicious about when we choose to go out and only do it appropriately.
John Pollard: Maybe as we wrap this up, could you summarize the main action items that we, our organizations, and our governments need to take to move this all forward?
Dr. Laura Copeland: Sure. I think we need to put a lot of energy into streamlining our workflows so that virtual care is something that can be sustained after this pandemic passes. It's unlikely that physicians or patients are going to tolerate a lot of time spent tinkering with technology or inefficient workflows when they no longer have to. So, I'd love to see that addressed.
We need to review policies and procedures. We need to consider is there some benefit in expanding upon licensing? There's been talks for years about national licensing. Would that be more efficient for our society, and what would the impact of that be? I know there's factions on both sides, but certainly something to consider again. Then we need to think about quality metrics, and how we can ensure we're providing good quality care when we have new options of perhaps not getting as fulsome of a physical exam as we're used to.
John Pollard: Great. What do you see as the future of virtual care? How do you see things going forward here after this COVID-19 experience is a little more in our rear-view mirror?
Dr. Laura Copeland: I'd like to think that we would sustain some of the gains that we have made. That's only going to happen if we manage to produce the infrastructure necessary to support it. But I would like to see most of our practices going to maybe 50, 60, 80% virtual.
And not only that, but I think we should take a good look at our hospital visits, and how many patients do we have sitting in the hospital for monitoring or low-intervention kind of visits that could actually be cared for from home? There are certainly many ways of doing home monitoring now that we could do virtually. So, I think we should be continuing to expand upon it.
John Pollard: Well, that is definitely a lot for us to get our mind around, and allow for us maybe to hope for as we move forward. Thank you, Dr. Copeland, for offering your breakdown on virtual care. All of us here at Nordic and at Healthtech, we appreciate your time and your insights.
Dr. Laura Copeland: Thanks a lot, John.