Authors: Tiffany Tse, Clare O'Connor, Pooja Patel
You are a resident coming in to see a patient who has come into the ED complaining of a new, sudden-onset, 9/10 pain headache. You run a CT scan and rule out any hemorrhage or stroke, referring them to the Stroke Prevention Clinic for a consultation. The patient asks if they can receive a virtual appointment for the future, as they live quite far away and would much prefer it.
You wonder if the virtual care provided would be appropriate for the type of care the patient needs. This leads you to think: how would one even determine what quality virtual visits mean to patients?
The healthcare system has found a need to shift to virtual care to adapt to the risks introduced by the 2019 novel coronavirus (COVID-19) pandemic to maintain patients’ health needs. In Ontario, Canada, 70% of all ambulatory visits were conducted virtually - over telephone or video - during the first three months of the pandemic.(1) Although it is unclear how long this modality of ‘virtual visits’ will stay, this care model is increasing in popularity due to its many benefits to patients.(2) For example, virtual visits can improve accessibility of care for patients from rural or more remote areas, as well as those located in areas with healthcare provider shortages. In-person appointments can pose a barrier for some patients due to the high costs of travel and parking, and considerations such as time off work or the need to find childcare.(3) Moreover, increased convenience, efficiency, and reduced travel and wait times can all contribute to higher patient satisfaction.(2) For example, Hamilton Health Sciences in Hamilton, Canada has attempted to quantify the travel saved by virtual appointments, estimating that they have saved patients and families 1.5 million kilometers of travel on average, per month.(personal communication, HHS) Although some patients prefer in-person appointments, virtual care is becoming an increasingly common option for certain types of encounters, such as those reviewing non-remarkable lab or imaging results.(3) Regardless of the modality offered, the ultimate goal of healthcare providers should be on offering the highest quality, patient-centred care. An integrated approach where providers partner with the patient to utilize the most appropriate option for each encounter is essential.
A quick Google search revealed a myriad of methods evaluating virtual care, but no standardized approach exists.(4) A tool to evaluate virtual care offerings may be beneficial, as the quality of care can differ significantly amongst healthcare providers, clinics, and institutions.(4) Recently, through interviews with patients, Hamilton Health Sciences’ Virtual Care Operations Team (VCOT) has been working to drive continuous quality improvement across its sites by updating the virtual care evaluation tools to ‘measure what matters.’ This has included looking at the six dimensions of quality, which ensures that virtual care projects are evaluated from a holistic lens.(5) The Institute of Medicine (IoM) established these six domains of healthcare quality, which was adapted by Health Quality Ontario to create the Quality Framework.(6) The six domains include: safe, effective, patient-centered, timely, efficient, and equitable care.(6) This framework provides guidance for creating indicators, benchmarking and setting targets to ensure that high-quality care is being provided.
To understand what quality virtual care means to patients, HHS collaborated with three cohorts of patient advisors to ask the following question: what does virtual care mean to you in relation to the six domains of healthcare quality? The groups that participated include the 1) Family Advisory Council 2) Youth Advisory Council and 3) Patient Advisors (corporate patient partners who contribute to a variety of projects), totalling 16 people. These conversations, despite their differing ages and contexts, demonstrate alignment between all three patient advisor populations.
A summary of the themes from these conversations can be found below:
Thematic response from HHS patient advisors
The resident listens to the patient, hearing their wishes for a virtual consultation. Because they live far away and have to take time off work to come in-person, it is much easier for them to meet via video virtual visit. The resident also confirms that they have a telephone and/or smart phone/video device with a reliable internet connection to participate in the visit. Although certain types of encounters may be more beneficial in-person, the resident reflects on the six dimensions of quality, and the clinical requirements of the consultation. As healthcare providers, our role is to equip patients with the proper tools and information, and partner with them as to the best way forward in their care.
Virtual care, while here to stay, is not a ‘one size fits all’ solution. When we think about evaluating virtual care, it’s often a multi-pronged approach, which includes understanding perspectives of both the patients and providers, as well as the healthcare organization. There is also a patient population that could be lost to follow-up if the only option is in-person. Further, evaluation should be ongoing so that continuous improvements to patient care can be made to ensure we are providing optimal patient care. These standards should be upheld, regardless of the type of visit - virtual or in-person.
So, we ask you, as a provider: what does it mean to you in regards to safety, effectiveness, patient-centredness, efficiency, timeliness, and equity when it comes to virtual care? What else would you consider when deciding if an appointment should be virtual or in-person?
Senior Editor: Dr. Darius Bägli
Copyedited by: Tiffany Tse
Stamenova V, Chu C, Pang A, Fang J, Shakeri A, Cram P, Bhattacharyya O, Bhatia RS, Tadrous M. Virtual care use during the COVID-19 pandemic and its impact on healthcare utilization in patients with chronic disease: A population-based repeated cross-sectional study. PloS one. 2022 Apr 25;17(4):e0267218.
Gajarawala SN, Pelkowski JN. Telehealth benefits and barriers. The Journal for Nurse Practitioners. 2021 Feb 1;17(2):218-21.
Reed ME, Huang J, Graetz I, Lee C, Muelly E, Kennedy C, Kim E. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA network open. 2020 Jun 1;3(6):e205873-.
Sartori DJ, Lakdawala V, Levitt HB, Sherwin JA, Testa PA, Zabar SR. Standardizing Quality of Virtual Urgent Care: Using Standardized Patients in a Unique Experiential Onboarding Program. MedEdPORTAL. 2022 Apr 12;18:11244.
Institute of Medicine - Six domains of health care quality  Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.
Health Quality Ontario. An overview of quality matters: Realizing excellent care for all. Ontario: Health Quality Ontario, 2017. 9 p. Retrieved from http://www.hqontario.ca/Portals/0/documents/health-quality/quality-matters-digital-english.pdf