June 2020Telehealth

How COVID-19 yanked telehealth out of the future and into our daily lives

After COVID-19, screens and phones will remain vital to care, experts predict

Imagine… using a computer and webcam to remotely diagnose a serious medical condition. Or give breastfeeding advice to a new mother. Or help a stressed-out teenager manage his anxiety.

It was a grand dream. But as the calendar flipped from 2019 to 2020, it all still sounded elusively futuristic.

In theory, performing assessments, checkups and counselling on a wide scale, with the expert in one location and the healthcare user in another, seemed to be just a matter of time.

But how much time? How long would it realistically take to clear the technical hurdles, obtain the government’s endorsement and earn the public’s trust?

No one was really sure.

“COVID-19 was definitely a catalyst for the type of change we’ve been talking about.”

And then, in early March, the future came calling. As the COVID-19 lockdown took hold, the order was issued: Implement telehealth—now!

Suddenly, staff at the JGH and in sites across CIUSSS West-Central Montreal were scrambling to figure out how healthcare users could receive the attention they needed, while isolated in the safety of their homes.

“COVID-19 was definitely a catalyst for the type of change we’ve been talking about and envisioning for quite a while,” says Dr. Justin Cross, the CIUSSS’s Chief Digital Health Officer.

“Of course, the pandemic was not the catalyst anyone wanted, because it was so disruptive and tragic in so many ways. But there’s no denying that it pushed us in the direction we needed to go.”

An array of telehealth programs

Within days, new telehealth services sprouted, while existing programs were broadened and strengthened. Among the most notable:

  • In the Goldman Herzl Family Practice Centre at the JGH, appointments using telehealth (also known as telemedicine) became the norm. By late May, the proportion of in‑person visits had plummeted to an averge of 12 or 13 per cent of all visits. During the first week of May, only 243 in‑person appointments were logged, versus 1,964 via telemedicine (video or phone). That week’s total of 2,207 is roughly the same as all of the in‑person, pre‑COVID-19 visits that Herzl used to handle in a typical week.
  • In the Segal Cancer Centre at the JGH, patients are now participating in virtual visits with their oncologist, as an alternative to face-to-face meetings. Patients are also monitored remotely via a personalized, virtual clinic, in which nurse navigators make contact via Zoom to help manage symptoms and, where needed, offer timely interventions.
  • In the field of mental health, video-conferencing is being used to conduct psychiatric and mental health assessments, “broadcast” helpful webinar presentations to a large audience, and arrange group discussions in the Youth Drop-In clinic.
  • The Côte-des-Neiges Birthing Centre is using Zoom for post‑partum checkups and breastfeeding support. Also, of the 10 to 14 appointments that a mother-to-be attends during her pregnancy, four or five are now conducted via telemedicine.
  • Under Dr. Nathalie Saad, the Tele-Pulmonary Rehabilitation Program has broadened its approach: It enables patients with pulmonary difficulties to remain at home and use a video link to speak with a healthcare professional about therapeutic exercises.
  • A pilot program is being planned by the JGH Division of Geriatric Psychiatry to provide support to groups of up to a dozen participants on Zoom. The group will be chaired by a clinician and will touch on subjects such as mindfulness-based cognitive therapy, life skills groups and problem-solving therapy.

“Our experiences during the pandemic clearly demonstrate why we need to embrace telehealth and take full advantage of its potential,” says Dr. Lawrence Rosenberg, President and CEO of CIUSSS West-Central Montreal.

“Even though the healthcare user and practitioner may be far from each other, the bond between them remains strong. Telehealth provides users with the reassurance that their needs can be taken care of quickly and properly.”

Anna D’Ambra, Clinical Telehealth Pilot for the CIUSSS and a Specialized Clinical Informatics Analyst with the Digital Health team, notes that some telehealth services did exist before COVID-19.

These included an earlier version of Dr. Saad’s Pulmonary Tele‑Rehabilitation Program, as well as some services at Herzl and a Telemedicine Vascular Health program for First Nations patients, among others.

However, she says, patients were generally not given permission to participate in a video conference at home. For the most part, they had to travel to a healthcare site to connect by video with the medical professional.

As well, these highly specific programs—aimed at patients with particular health conditions—were often championed by a doctor or a healthcare professional who had a strong interest in digital technology.

Ministry of Health clears the way

A key reason for the pre-COVID-19 scarcity of telemedicine, explains Dr. Cross, was the lack of widespread reimbursement by the Ministry of Health and Social Services to physicians for most telehealth activities. Payment was made “only for a certain kind of doctor or a certain kind of service,” he says.

According to Dr. Saad, the government sometimes also insisted that communication be facility-based—that is, having a doctor at a computer screen in one healthcare institution, and a patient at a screen in another.

The watershed moment came this past February, just before COVID-19 struck.

In some cases, this proved helpful. It became possible, for example, for a physician in a Montreal establishment to counsel a patient in a facility in remote region of Quebec. But it still meant that the patient had to make an inconvenient trip from home to the local healthcare institution.

The watershed moment came this past February, just before COVID-19 struck the province. The Ministry realized that to prevent the spread of the virus, most patients (and many members of staff, including some clinicians) had to stay away from hospitals and certain other healthcare facilities.

So, moving quickly, the government “approved reimbursement for most physician services that were delivered by video and telephone,” says Dr. Cross.

Another major step by the Ministry of Health was to negotiate directly with Zoom for “accounts that met higher standards of security and encryption,” says Dr. Marc Miresco, Director of Adult Psychiatric External Services in the Institute of Community and Family Psychiatry at the JGH.

Care anywhere: The hospital at home

By this point, the Digital Health team had been up and running for a couple of months, with a mandate to bring to life Dr. Rosenberg’s vision: enabling care to be provided to healthcare users, no matter where they might be located—in essence, a hospital at home.

The original, pre-pandemic plan was to conduct a steady and briskly paced transition toward telehealth. But once COVID-19’s considerable risks and hazards became apparent, the pace of the process picked up considerably.

Of key importance in getting team members up to speed was Sabine Cohen, Associate Director of Digital Health, whose role includes responsibility for the crucial area of information security. As well, Ms. Cohen acted as liaison with the Ministry of Health in implementing a version of Zoom with stronger security.

“We’re not saying—and we’ve never said—that in-person visits will be discontinued.”

Initially, there may have been skepticism among some patients and clinicians about what could be accomplished during appointments that were not conducted face to face. However, users soon discovered that telehealth did, indeed, allow them to get the care they needed in a safe and confidential manner.

For example, they could be treated for common primary-care conditions (such as rashes and some infections), as well as assessments of the way they managed their chronic conditions.

A smaller number also continue to record their vital signs from home. Using iPads and specialized software, they enable their healthcare providers to more effectively monitor chronic conditions such as diabetes, hypertension and chronic obstructive pulmonary disease (COPD).

“We’re not saying—and we’ve never said—that in-person visits will be discontinued,” Dr. Cross insists.

“In many cases, the patient does need a physical exam or needs to be present in person when the relationship with the healthcare provider is being established.

“What we are saying, however, is that many visits just don’t need to happen in person. A large number of conditions are simple and straightforward, and they can be treated over a distance.”

Michael Shulha (Ph.D.), Associate to the Director for Digital Health, says clinicians have found that their patients appreciate the way virtual visits help reduce possible exposure to COVID-19.

“The clinicians have also told us that patients like being able to keep an appointment without having to take time off work, search for an expensive parking spot, or find a babysitter,” he says.

“They see all of these conveniences as real benefits.”

Mr. Shulha adds that the Digital Health team has begun exploring the subject more rigorously by collaborating on a user survey with the CIUSSS’s Quality Department (see sidebar).

“We hope to arrive at a more systematic assessment of how telehealth has been functioning for patients and professionals alike.

“Over all, we expect the reaction to be positive, because many people are happy they were able to maintain contact with their healthcare providers during such a difficult time.”

High marks for telehealth in survey of JGH patients

In a survey conducted by the Digital Health and Quality teams, healthcare users at the JGH have expressed solid approval in response to questions about their experiences using telehealth.

Of those surveyed, a total of 90 per cent agreed they would use telehealth again, including 63 per cent who strongly agreed they would do so.

Asked whether they would recommend the service to family and friends, 70 per cent replied that they definitely would, with another 21 per cent saying they probably would.

Opinions were sought about telehealth (termed “virtual health” in the survey) from patients who had used the service by phone or video in April during the coronavirus (COVID-19) lockdown.

At the time when the survey was conducted, telehealth was considered a necessary alternative to in-person visits to ambulatory clinics at the Goldman Herzl Family Practice Centre and various departments at the JGH.

A total of 212 surveys were completed over two weeks in April, a response rate of 29 per cent. This is considered a statistically valid response rate for surveys of this sort.

Among the other findings, here is the proportion of those for whom:

• This was their first telehealth appointment: 82 per cent

• Telehealth responded to their needs: 70 per cent strongly agreeing, with another 23 per cent somewhat agreeing

• The telehealth appointment improved their access to health care: 57 per cent strongly agreeing, with another 33 per cent somewhat agreeing

• Using telehealth made them feel safer than going to a hospital clinic: 67 per cent strongly agreeing, with another 19 per cent somewhat agreeing

Taking medical expertise to the regions

Among the most vigorous telehealth advocates is Dr. Nathalie Saad, who began using digital technology as far back as 2017 to make her expertise in pulmonary rehabilitation available to patients across Quebec.

Today she is the CIUSSS’s physician-champion of telehealth, in addition to serving as a JGH respirologist and Director of the Outpatient Pulmonary Rehabilitation Program at Mount Sinai Hospital.

Dr. Nathalie Saad

Dr. Nathalie Saad

Dr. Saad’s ongoing objective has been to provide Quebec-wide support to individuals who need help in managing their COPD, the #1 cause of recurring visits to the Emergency Department.

However, in its original incarnation, her program had to conform to a number of government-imposed limitations: It could be implemented only if patients drove or flew to Montreal, lived at Mount Sinai for three weeks and received in-person instruction on handling their COPD.

Given the impracticality of this arrangement, Dr. Saad worked with hospitals across the province to update the program and spare patients the exhausting, unsettling trip to Montreal.

Instead, they were able to visit to their nearby healthcare facility and connect with Dr. Saad’s team via telehealth. At the same time, they continued to be seen in person by their own local treating team, which might include a medical specialist, family physician, nurse or respiratory therapist.

Since 2017, this tele-pulmonary rehab program has helped more than 300 patients in seven centres, some in the general Montreal region (Verdun, Joliette) and others farther away (Abitibi, Outaouais, Lanaudière).

“The biggest difference since March 11 is that now we can actually reach out to patients in their homes,” says Dr. Saad. “Because of the pandemic, we’ve adapted our program to be able to provide instruction to our patients and get them to exercise at home.

“This is the exact same training they’d get if they were with us at Mount Sinai or connected to us at the designated site in their regions.”

Telehealth: Post-COVID-19?

Despite her commitment to telehealth, Dr. Saad cautions that this new, digital approach is not meant as a substitute for all face-to-face visits between patients and their treating physicians. “That’s one of the reasons I’m convinced that the changes will stick, once we’ve put COVID-19 behind us,” she says.

“However, we have to do it right. We have to stop seeing telemedicine as being different from a regular clinic. This means we need appointments, we need structure, we need systematic follow-ups, we need to be able to get test results and, where necessary, we need the flexibility to see the patient in person in the clinic.”

Mr. Shulha agrees, noting that the primary mission of the CIUSSS’s Digital Health team in a post-COVID-19 world will be to continue the maturation process and embed telehealth more deeply in the daily workflows of the healthcare network, wherever its presence makes sense.

“COVID-19’s presence has motivated us to use our imagination to encourage innovation.”

The team will also be looking at ways—some of which may previously have been unforeseen—of putting telehealth to entirely new uses, says Danina Kapetanovic, who is spearheading the Innovations and Entrepreneurship Program in the office of the President and CEO.

“COVID-19’s presence has motivated us to use our imagination to encourage innovation and to make us ask where the technology might be implemented and where we might find the kind of innovation that we can initiate,” she says.

“Telehealth is not limited to just a video-type visit,” adds Anna D’Ambra. “When properly implemented with features like remote patient monitoring, it’s actually going to allow patients to take ownership of their health and well-being, and be engaged in their own care.

“What we’re seeing now is really just the beginning—only a hint of what awaits us and a preview of what the future holds for us.”

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