Abstract

The COVID-19 pandemic changed Canadian health care almost overnight. The need to contain the virus’ spread — while maintaining access to health services — prompted the swift deployment of virtual care tools and services. Immediately after the COVID-19 pandemic was declared in March 2020, Canada Health Infoway (Infoway), Health Canada and the provinces and territories began working together to help provide urgently needed programs and services that could have immediate impact as well as continued value post-pandemic. Infoway established a Rapid Response to COVID-19 fund by reallocating $35 million of its existing funds. The program resulted in 17 projects being launched across all jurisdictions, in four focus areas: virtual visits, e-mental health, remote patient monitoring and access to COVID-19 test results. 

The Rapid Response to COVID-19 initiative demonstrates how aligned priorities and strong collaboration acted as drivers for the rapid identification and deployment of virtual services. As of March 31, 2021, 3.5 million Canadians and more than 91,000 health care providers had logged more than five million uses of virtual care solutions as a result of these investment projects. This paper will examine the factors that impacted the Rapid Response program’s success, key learnings and next steps.  

Background

The COVID-19 pandemic changed Canadian health care almost overnight. The need to contain the virus’ spread prompted the health system to reevaluate the “costs of physical contact” (e.g. potential virus exposure, and costs associated with personal protective equipment and enhanced cleaning measures1). For most routine appointments, those potential costs suddenly exceeded the benefits to patients and providers.

In such circumstances, virtual care offered a safe alternative to many in-person appointments. By enabling Canadians to connect with their care providers remotely, virtual care had the potential to reduce the risks and costs of in-person visits2, while simultaneously ensuring that Canadians could continue accessing the care they needed. 

The Rapid Response to COVID-19 

The Rapid Response to COVID-19 initiative is an example of how aligned priorities and strong collaboration acted as drivers for the rapid identification and deployment of virtual services. As soon as the pandemic was declared, Infoway and Health Canada convened the provincial/territorial governments to identify their immediate needs to ensure that Canadians continued to receive safe care. The jurisdictions quickly identified four priority areas: 

  • Accelerate the provision of virtual visits
  • Meet the increased demand for e-mental health services 
  • Increase capacity to monitor patients remotely  
  • Allow Canadians to access to COVID-19 test results online

Infoway’s Rapid Response initiative was designed around funding projects that would accelerate these common priorities.  Project proposals were received from all 13 provinces and territories, with 17 projects approved within 45 days. All projects were operational within 30 days of their respective approvals and monthly utilization of users (both providers and citizens) was tracked.  

Four Drivers for Success

Many longstanding barriers to virtual care adoption — for instance, remuneration and hesitation among patients and providers — were dismantled in the pandemic’s early weeks through policy changes and fear of virus transmission3. However, while these circumstances helped make the widespread adoption of virtual care possible, they did not guarantee successful deployment on their own. 

As observed in a recently published paper, digitization alone is not true digital transformation, nor does it necessarily lead to it4. While clinicians and patients were obliged to adapt to new modalities of care, the underlying technologies — such as telephones, patient portals, email — were not inherently new. Rather than the technologies, it was the approach and stakeholder effort that contributed most significantly to the successful implementation of the COVID-19 Rapid Response program. 

In particular, four factors substantially impacted the program’s success:
  • Excellent stakeholder relationships: Federal, provincial and territorial governments, Infoway and other key stakeholders have strong working relationships. Program development benefited from extensive shared knowledge of local needs and challenges, and prior experience with virtual care. At all levels, a sense of common purpose in response to a common crisis focused attention.
  • Established and proven funding models: Infoway has a long history of working with Health Canada and the jurisdictions to invest in digital health advancement. Experience with and understanding of the process accelerated roll-out of the investment program.  Furthermore, extensive experience with gated funding models and adoption-dependent reimbursement (i.e. reimbursement contingent upon eligible costs and successfully meeting adoption targets) laid a foundation for the COVID-19 Rapid Response projects to quickly achieve substantive measurable outcomes. 
  • Strong solution foundations: Advancement of digital health has been significant over the last decade, as seen through widespread use of electronic health records (EHRs), electronic medical record (EMR) systems, patient portals and telehealth — all of which played a critical role in positioning Canada to address the challenges of COVID-19. Governments, industry, clinicians and Infoway were able to build upon established technology, and to take advantage of enabling policies and enhanced delivery capacity. 
  • A coordinated approach and capacity for rapid response: Collaboration between Infoway and the jurisdictions began as soon as the pandemic was declared. Recognizing the need for action, provinces and territories were quick to mobilize around virtual care, and coordination efforts by Infoway expedited planning and approval processes. This flexibility and ability to streamline processes enabled the rapid deployment of virtual care solutions across all 13 provinces and territories, ensuring that as many Canadians as possible had access to virtual care as quickly as possible. 

Project Results 

In a rapidly evolving crisis, stakeholders had little knowledge about how the situation would unfold. Using the best available benchmarks, targets were therefore set conservatively; performance results substantially exceeded them. 

As of March 31, 2021, 3.5 million Canadians (almost triple the program target) and more than 91,000 health care providers (exceeding the program target) had logged more than five million uses of virtual care solutions as a result of these investment projects.

 

Figure 1. Canadians Using Virtual Care as a Result of the COVID-19 Rapid Response Investments

Figure 1

 Source: Canada Health Infoway 2020-2021 Annual Report

 

Figure 2. Providers Using Virtual Care as a Result of the COVID-19 Rapid Response Investments

Figure 2

Source: Canada Health Infoway 2020-2021 Annual Report

While further work is required to optimize virtual care, these results are exceptional given the tight approval timelines and emergency setting. They represent a strong foundation for sustained virtual care use, which is desired by a strong majority of both patients and clinicians.5, 6

Interjurisdictional Collaboration: A Case Study

New Brunswick implemented a secure portal through the MyHealthNB website to enable eligible citizens to obtain faster access to their COVID-19 test results. As a result, more than 186,000 citizens (more than one in five New Brunswickers) were able to access their test results over a 12-month period. 

As a result of jurisdictional collaboration enabled through Infoway’s National Leaders Forum, Manitoba was able to learn from and replicate New Brunswick’s model. Manitoba launched the Shared Health COVID-19 Online Results Display to provide Manitobans with secure access to their COVID-19 test results. And by leveraging the work done in New Brunswick, Manitoba was able to implement this solution within weeks. As a direct result of this interjurisdictional collaboration, knowledge sharing and alignment of priorities, 245,000 Manitobans were able to access their COVID-19 test results. 

Discussion and Key Learnings 

Where past attempts to implement virtual care have often been driven by the needs of individual organizations7, the pandemic precipitated a situation in which priorities were aligned across a broad cross-section of stakeholders: from the jurisdictions and policymakers, to clinicians and medical associations, to patients and the vendor community. Past analyses have observed that lack of leverage has historically posed a challenge to virtual care adoption.8  As noted above, Canadians’ options for accessing care were limited prior to the pandemic. The health crisis provided the leverage for change, while jurisdictional collaboration enabled progress to be intentionally realized.

As noted in a prescient paper by Desveaux et al, clear mission and clear definition of roles and responsibilities are critical to the success of health care transformation.9 The COVID-19 Rapid Response initiative highlights  the importance of such clarity: Health Canada, the jurisdictions and Infoway each brought clearly-defined resources, expertise and responsibilities to the collaboration. Moreover, with common issues and similar projects in every province and territory, the jurisdictions benefited directly from their counterparts’ expertise as program and clinical leads exchanged knowledge and resources to support the implementation of their projects.  

Across jurisdictions, there were similar risks to be managed. For example, common approaches to privacy and security were essential to enabling rapid action. National leadership around privacy and security enabled leading practices to be applied across projects, and risks to be managed while avoiding unnecessary project delays.  

The volume of work and the need for an immediate and urgent response to the COVID-19 emergency made it clear that the work was more than any one jurisdiction might manage alone. Leveraging capacity and expertise from partners at provincial, territorial and federal levels was therefore necessary for project success across Canada.  

While the importance of change management was well-understood, change activities were constrained in the short term. As research and reflection continues, there is greater understanding of the substantive change required in areas like workflow and integration of tools and processes on the clinical level, reimbursement on the policy level and interoperability on the technology level.10, 11, 12  

Often, digital health progress has occurred unevenly across the country, but surveys demonstrated that through the COVID-19 Rapid Response initiative, the uptake of virtual care was much more consistent and consistently beneficial across the country.13, 14 These projects demonstrated the substantial appetite for — and potential of — virtual care, and they  reflect the beginning of the journey to its truly effective and sustainable integration into the health system.

Conclusions and Next Steps

While the COVID-19 Rapid Response initiative was deployed in response to an acute public health crisis, its success has broader implications for the future of Canada’s health system. This initiative proved that under the right conditions, with a common mission and strong collaboration, substantive health system change is possible at a rapid pace. When it mattered most, virtual care in Canada advanced further in six weeks than it had in the previous six years. 

Findings from the COVID-19 Rapid Response program demonstrate that patients and providers are highly satisfied with virtual care. It provides significant time and cost savings for Canadians and it improves access to care and health system capacity. Effectively leveraged, the foundation laid as a result of these projects can benefit Canadians today and into the future. 

Next Steps

While the right technologies and tools must be in place to support virtual care adoption, fiscal and policy drivers and change management will be key to its sustained use. To build on the success of the Rapid Response program and the resulting projects, it will be necessary to focus attention in several key areas:

  • Addressing significant barriers to virtual care access, which impact significant segments of the population;
  • Providing change management support for clinicians and the health workforce, and digital health literacy support for patients, families and caregivers; 
  • Better understanding best practices and use cases for virtual care, and determining its role in a post-pandemic health system; 
  • Continuing to invest in modern virtual care solutions and interoperability to ensure clinicians and citizens have access to the right tools and information; and, 
  • Continuing to collaborate, sharing information and resources that can benefit multiple jurisdictions.

The COVID-19 Rapid Response program demonstrated that identification of common priorities, coordination of effort and unprecedented collaboration is very effective in accelerating virtual care in Canada. Continuing these successful practices in a post pandemic world will enable a truly modernized health system, for the better health of all Canadians. 

About the Author

Simon Hagens, Senior Director, Performance Analytics, Canada Health Infoway

Krista Balenko, Senior Director, Program Delivery, Canada Health Infoway

Waldo Beauséjour, Analyst, Performance Analytics, Canada Health Infoway

Sangita Nadarajah, Senior Project Associate, Canada Health Infoway

Katie Bryski, Content Administrator, Canada Health Infoway

References

Bhatia, R. Sacha, Jamieson T, Shaw J, Piovesan,C, Kelley, L.T., Falk, W. (2020). Canada’s Virtual Care Revolution: A Framework for Success. Commentary 586. Toronto: C.D. Howe Institute. Available online at: https://www.cdhowe.org/sites/default/files/attachments/research_papers/mixed/Commentary_586.pdf (Accessed 21 Sept 2021).

Bhatia RS, Shojania KG, Levinson W. Cost of contact: redesigning healthcare in the age of COVID. BMJ Quality & Safety 2021;30:236-239.

Bhyat R, Hagen S, Bryski K, Kohlmaier, J. Digital health value realization through active change efforts. Frontiers of Public Health. 2021 Sept. doi: 10.3389/fpubh.2021.741424.

Brunet F, Malas K, Desrosiers ME. Will telemedicine survive after COVID-19? Healthc Manage Forum. 2021 Sep;34(5):256-259. doi: 10.1177/08404704211031264. Epub 2021 Aug 3. PMID: 34340570.

Canada Health Infoway. 2020-2021 Annual Report – Celebrating 20 Years of Progress. (2021). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/3899-annual-report-2020-2021/view-document?Itemid=101 (Access 17 Sept 2021).

Canada Health Infoway. Canadian Digital Health Survey: What Canadians Think. (2020). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3856-canadian-digital-health-survey-what-canadians-think?Itemid=101 (Accessed 22 Sept 2021).

Canadian Medical Association and Canada Health Infoway. 2021 National Survey of Canadian Physicians. (2021). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3935-2021-national-survey-of-canadian-physicians?Itemid=101 (Accessed 22 Sept 2021).

Canadian Medical Association. Virtual Care Recommendations for Scaling Up Virtual Medical Services — Report of the Virtual Care Task Force. (2020). Available online at: https://policybase.cma.ca/documents/PolicyPDF/PD20-07.pdf (Accessed 20 Sept 2021). 

Desveaux L, Soobiah C, Bhatia RS, Shaw J. Identifying and Overcoming Policy-Level Barriers to the Implementation of Digital Health Innovation: Qualitative Study. J Med Internet Res. 2019 Dec 20;21(12):e14994. doi: 10.2196/14994. PMID: 31859679; PMCID: PMC6942191.

Digital Health Canada Chief Executive Forum. Virtual Care in Canada: Maturity Model Framework. (2021). Available online at: https://chief.digitalhealthcanada.com/wp-content/uploads/2021/01/Virtual-Care-National-Maturity-Model-vJAN2521.pdf (Accessed 24 Sept 2021).

Shaw J, Tepper J, Martin D. From pilot project to system solution: innovation, spread and scale for health system leaders. BMJ Leader 2018;2:87-90. 

Footnotes

1 Bhatia, R. Sacha, Jamieson T, Shaw J, Piovesan, C, Kelley, LT, Falk, W. (2020). Canada’s Virtual Care Revolution: A Framework for Success. Commentary 586. Toronto: C.D. Howe Institute. Available online at: https://www.cdhowe.org/sites/default/files/attachments/research_papers/mixed/Commentary_586.pdf (Accessed 21 Sept 2021).

2 Bhatia RS, Shojania KG, Levinson W. Cost of contact: redesigning healthcare in the age of COVID. BMJ Quality & Safety 2021;30:236-239.

3 Bhatia RS, Shojania KG, Levinson W. Cost of contact: redesigning healthcare in the age of COVID. BMJ Quality & Safety 2021;30:236-239.

4 Bhyat R, Hagen S, Bryski K, Kohlmaier, J. Digital health value realization through active change efforts. Frontiers of Public Health. 2021 Sept. doi: 10.3389/fpubh.2021.741424. 

5 Canada Health Infoway. Canadian Digital Health Survey: What Canadians Think. (2020). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3856-canadian-digital-health-survey-what-canadians-think?Itemid=101 (Accessed 22 Sept 2021).

6 Canadian Medical Association and Canada Health Infoway. 2021 National Survey of Canadian Physicians. (2021). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3935-2021-national-survey-of-canadian-physicians?Itemid=101 (Accessed 22 Sept 2021).

7 Desveaux L, Soobiah C, Bhatia RS, Shaw J. Identifying and Overcoming Policy-Level Barriers to the Implementation of Digital Health Innovation: Qualitative Study. J Med Internet Res. 2019 Dec 20;21(12):e14994. doi: 10.2196/14994. PMID: 31859679; PMCID: PMC6942191.

8 Shaw J, Tepper J, Martin D. From pilot project to system solution: innovation, spread and scale for health system leaders BMJ Leader 2018;2:87-90.

9 Desveaux L, Soobiah C, Bhatia RS, Shaw J. Identifying and Overcoming Policy-Level Barriers to the Implementation of Digital Health Innovation: Qualitative Study. J Med Internet Res. 2019 Dec 20;21(12):e14994. doi: 10.2196/14994. PMID: 31859679; PMCID: PMC6942191.

10 Canadian Medical Association. Virtual Care Recommendations for Scaling Up Virtual Medical Services — Report of the Virtual Care Task Force. (2020). Available online at: https://policybase.cma.ca/documents/PolicyPDF/PD20-07.pdf (Accessed 20 Sept 2021).

11 Digital Health Canada Chief Executive Forum. Virtual Care in Canada: Maturity Model Framework. (2021). Available online at: https://chief.digitalhealthcanada.com/wp-content/uploads/2021/01/Virtual-Care-National-Maturity-Model-vJAN2521.pdf (Accessed 24 Sept 2021).

12 Brunet F, Malas K, Desrosiers ME. Will telemedicine survive after COVID-19? Healthc Manage Forum. 2021 Sep;34(5):256-259. doi: 10.1177/08404704211031264. Epub 2021 Aug 3. PMID: 34340570. 

13 Canada Health Infoway. Canadian Digital Health Survey: What Canadians Think. (2020). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3856-canadian-digital-health-survey-what-canadians-think?Itemid=101 (Accessed 22 Sept 2021).

14  Canadian Medical Association and Canada Health Infoway. 2021 National Survey of Canadian Physicians. (2021). Available online at: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3935-2021-national-survey-of-canadian-physicians?Itemid=101 (Accessed 22 Sept 2021).