Introduction

Proponents of virtual care have long touted its potential to improve access to and quality of care, and to produce cost and time savings for patients. More recently, the potential environmental benefits of virtual care have also garnered attention. These benefits derive most demonstrably from the reduction in patient travel (for primary care and specialist care) and its associated reduction in carbon emissions (and resultant harms¹), though in the longer term they may also arise in relation to virtual care’s potential to reduce facility size and improve health outcomes. While the latter benefits are difficult to quantify at present, there is a growing number of studies that seek to measure the reduction in emissions due to avoided travel from the use of virtual care.

This focus is warranted given that transportation of people and goods contributes significantly to overall health sector carbon (CO2) emissions. The National Health Service (NHS) in the United Kingdom attributes approximately 9% of its total carbon footprint to “personal travel,” which includes trips made by employees (4%), patients (5%), and visitors (1%) to care facilities². Reducing unnecessary journeys represents an important pathway to reducing personal travel emissions, and virtual care clearly has a key role to play in this process, though as Purohit et al note in their recent systematic review of the evidence on the carbon footprint of telemedicine, the clinical and environmental benefits of virtual care must be considered in relation to the local context³. Here, we report estimates for the environmental benefits associated with virtual care services utilization in Canada based on the results of the Canada Health Infoway Canadian Digital Health Survey 2021: What Canadians Think. We then consider how these benefits can be maintained and maximized in the Canadian context, particularly as the country adjusts to the rapidly-shifting virtual care landscape wrought by the COVID-19 pandemic.

Background 

Over the past decade, the Canadian health care landscape has seen significant advancements in digital health, such as the growth of primary and ambulatory care electronic medical records (EMRs) as well as the foundational pieces that support a longitudinal patient electronic health record (EHR). Increased adoption of patient-facing technologies such as visits through videoconferencing, remote patient monitoring and e-mental health, along with growth in patient engagement, have enabled significant progress for health care in Canada. 

Canada has long been a leader in the provision of specialty care via videoconferencing to rural and remote communities. Today, telehealth programs across the country routinely provide care to communities hundreds of kilometres from the nearest hospitals, with demonstrated benefits in terms of avoided travel for patients and providers, avoided hospitalizations and emergency department visits, and improved health outcomes due to more timely care⁴. While avoided travel is not nearly as impactful for individual patients residing in densely populated areas, at the societal level those savings add up and translate into meaningful reductions in CO2 emissions. Moreover, while reduced travel and hospitalizations produce immediate emission reductions, improved health outcomes can produce downstream benefits in the form of reduced health sector activity. In addition to convenience and improved health outcomes, the infrastructure that has been put in place over the years to facilitate virtual service delivery in rural and remote communities has also produced environmental benefits.  

The ongoing COVID-19 pandemic has sparked a rapid uptake in digital health services, particularly virtual care—any interaction between patients and/or members of their circle of care, without direct contact and in real or non-real time, using any form of communication or information technology. Prior to the pandemic, only 10-20% of all primary care visits in Canada were held virtually⁵. Just after the onset of the pandemic, physical distancing guidelines implemented to reduce the risk of infectious disease transmission led to dramatic changes in the provision of care, with a shift to approximately 60% of all visits held virtually. These visits occurred by telephone, video, and in some cases through secure messaging/email⁶. As we learned to live with COVID-19 and the necessary public health measures, this number decreased to roughly 33% of patient-reported health care visits between January 2021 and March 2022, with ebbs and flows mirroring the onset of various waves of the disease. Approximately 75% of virtual visits tracked since April 2020 were conducted by telephone, 21% were by video and the rest were via secure messaging⁷.  

The increased availability of virtual options offers reported benefits in the form of improved access, reduced risk of disease transmission and improved convenience for  patients and providers8,9.  However, although the environmental benefits associated with the utilization of virtual care have also presumably increased with this ramp up, these have yet to be documented.

Beyond improving our understanding of how virtual care could mitigate the health sector’s impact on the environment and associated impacts to human health, a better sense of the short and long-term environmental value of virtual care—particularly when it comes to potential carbon reductions—could prove to be an important decision-making factor for patients considering the merits of a virtual visit, or of virtual care in general. The majority of Canadian adults (80%) are concerned about climate change. However, awareness of the contribution of the health care sector to climate change remains relatively low in Canada. According to the Canada Health Infoway Canadian Digital Health Survey 2021: What Canadians Think, only 38% of Canadian adults are aware that the health care sector contributes to greenhouse gas emissions. Similarly, while the COVID-19 pandemic has spurred a massive adoption of digital health, less than half of Canadians (47%) are aware of the contribution of virtual care in reducing health care’s greenhouse gas emissions. Nevertheless, 69% of Canadians would be more likely to use virtual care if they knew it can reduce health care’s contribution to climate change¹⁰. 

Methods

The main focus of our analysis was to generate estimates for the environmental benefits associated with virtual care services utilization using data from the Canadian Digital Health Survey 2021: What Canadians Think, conducted between July 14 and August 6, 2021. This cross-sectional and bilingual survey is an annual citizen-based data collection that tracks digital health awareness, access, utilization and perceptions. Besides these core factors, the 2021 iteration generated data on Canadians’ attitudes toward virtual care and health system sustainability. A sample of 12,052 Canadians aged 16 years and over was drawn from a web panel of nearly 500,000 representative panelists from all regions of Canada. A full description of the sample is provided in the survey report¹¹.

We arrived at estimates of virtual care’s carbon savings through three main steps: (1) definition of several key metrics; (2) identification of the data sources for the computations; and (3) the calculation process. We defined two sets of output metrics: (1) the environmental benefits of virtual care; and (2) the negative health outcomes avoided as a result of virtual care use. While for the first set we used the emission of CO2 avoided, the second set referred to social cost of carbon (SCC) and years of full health saved. These three metrics were defined as follows:

• The CO2 emission is the main output metric of the analysis. It was calculated in kilogram of CO2 equivalent (kgCO2eq) and reported in tonne of CO2 equivalent. 
• The SCC is an economic measure of the negative health outcomes associated with the emission of one additional tonne of CO2 in the atmosphere¹². It was estimated in Canadian dollars (CAD).
• Years of full health saved as a result of the use of virtual care services correspond to disability-adjusted life of years (DALYs). The latter is a time-based metric of overall burden of disease borne by populations¹³.

The process for generating the estimates for the output metrics consisted of two stages: (1) computation of the estimates for the survey sample; and (2) extrapolation to the overall Canadian population. While the input metrics were derived directly from the survey questions, the output metrics were generated from calculation. We multiplied average values calculated for the survey sample by 2021 population statistics from Statistics Canada to extrapolate to the overall Canadian population, and by SCC data from Environment and Climate Change of Canada to calculate negative health outcomes avoided. We multiplied extrapolated distance by an emission factor for a mid-sized passenger vehicle (0.2656 kgCO2eq/km¹⁴). We applied demographic weights from Canadian census data to the survey results to compensate for over- and under-representation of certain demographic groups in the sample collected.

Estimates generated for the environmental impact of traditional telehealth programs aimed at rural and remote communities were based on the methodology developed in the 2011 Telehealth Pan-Canadian Study¹⁵.  

Our analysis hinged heavily on descriptive statistics (mean and proportions) and graphs. (See the Appendix for the equations used to generate all estimates.)

Analysis

Volume of virtual care visits

We estimated that Canadians had 57.5 million virtual care encounters in 2021, including 45.9 million phone consultations, 9.6 million by videoconferencing and two million by secure messaging. 

Rural Canadians reported the lowest volume of virtual care visits (8.6 million). However, traditional telehealth consultations linking acute care centres in urban areas with endpoints in rural and remote communities accounted for an additional one million consultations.

Travel distance avoided

Canadians avoided a total of 1.2 billion km in travel distance as a result of virtual care utilization in 2021 (phone, videoconferencing, secure messaging and telehealth). On average, rural Canadians traveled longer distances to see their regular health care provider (35.7 km) than those living in small or medium population centres (18.3 km) and large urban centres (12.6 km).

Carbon emissions avoided

Based on visit volumes, travel distance avoided, and an emission factor for a mid-sized passenger vehicle of 0.2656 kgCO2eq/km¹⁶, we estimate that in 2021, virtual care reduced CO2 emissions by an estimated  330,000 metric tonnes. 

Figure 1. Carbon saving estimates (in metric tonnes of CO2eq) associated with virtual care services utilization in 2021

This reduction in CO2 emissions is equivalent to taking more than 72,000 passenger vehicles off the road for one year, providing electricity for more than 60,000 homes for one year, or the amount of carbon sequestered by 5.5 million tree seedlings grown for 10 years¹⁷. 

Figure 2. CO2 savings in 2021 are equivalent to…

Negative health outcomes avoided

Besides the immediate environmental impacts, CO2 emissions have the potential to cause health problems, with social and economic implications¹⁸. The SCC saved from the reduction of 330,000 tonnes of CO2 was estimated at $13.5 million CAD. Moreover, an estimated loss of 230 DALYs was avoided as a result of the use of virtual care in 2021.

Discussion

Virtual care reduces the need to travel to receive health care, thereby lowering travel-related carbon emissions. This model of care therefore has the potential to generate immediate environmental benefits. However, although there are several factors specific to the Canadian context that amplify this potential, there are some important caveats to consider as we work to advance our understanding of virtual care’s impacts.   

In Canada, the potential to reduce the environmental harms of health care through virtual care delivery holds particular promise. Nationally, the fleet of personal vehicles is still comprised almost entirely of gasoline-powered vehicles¹⁹.  Reducing the unnecessary use of these vehicles will result in more significant environmental benefits than in places with a much higher proportion of hybrid or electric vehicles. Moreover, while the information and communication technology (ICT) used to facilitate virtual visits (such as smartphone and video calls) does have an environmental footprint²⁰, it is not as large when it is powered by non-emitting energy sources. There are several Canadian provinces with relatively clean (that is, non-emitting) energy grids. Ontario’s power grid, for example, derives 82% of its electricity from non-emitting sources such as hydro and nuclear power. Also relevant to ICT emissions is the mode of virtual care delivery. In Canada, virtual care can now be accessed by patients via their smartphones and/or personal computers from home, lessening the need for the more carbon intensive ICT set-ups that characterized virtual care in its initial permutation, telemedicine²¹. In fact, the most common mode of virtual care delivery in 2021 was the telephone, which has fewer emissions than video streaming²². Under these conditions, an uptick in virtual care means that primarily fossil fuel burning vehicle travel to care facilities can be replaced with primarily clean-energy-powered and relatively low-emitting ICT²³.

Prior to the COVID-19 pandemic, any significant environmental benefits associated with virtual care seemed a long way off, since adoption rates across the country were relatively low. The pandemic has brought virtual care into the mainstream of care delivery, and the environmental benefits associated with reduced travel emissions have suddenly become far more potent. However, as patients and providers have discovered, not all in-person care interactions can or should be replaced with virtual care. Infoway’s Canadian Digital Health Survey 2021: What Canadians Think, identified prescription renewals, new prescriptions, and advice on the issue/concern that prompted the visit as the most frequent outcomes of a virtual visit—a good indication of the most appropriate use cases for these care delivery modalities. Conversely, the same survey showed that in about 20% of cases, there was still a need to refer someone to in-person consultation either for urgent or primary/community care. As the pandemic subsides, virtual care will likely stabilize at a rate somewhere between pre- and peak-pandemic rates that reflects its suitability for certain types of interactions, and the associated carbon savings from avoided travel will also drop. The emission reductions that can be achieved via a more appropriate and sustainable rate of virtual care provision are still significant. The NHS, for example, cites a remote care target rate of 25% for outpatient activity in cases where outpatient attendance is clinically necessary—a target that will lead to “direct and tangible carbon reductions²⁴.” 

The environmental benefits of virtual care should only be one of many considerations used to determine the suitability of a virtual vs. in-person visit. In its draft clinical guidance on adopting and integrating virtual visits into care, Ontario Health offers a list of factors for providers to consider in selecting patients for virtual visits, including language, mobility, convenience, parking costs and access to appropriate ICT²⁵.  We suggest that potential emission reductions be added to such considerations—a move supported by Infoway’s survey finding that 69% of patients would be more likely to opt for a virtual visit if they knew it would result in carbon savings.

There are, however, several important caveats that must be considered with respect to our understanding of and ability to maximize the environmental benefits of virtual care. First, our analysis, like many others, captures only travel related carbon reductions associated with virtual care. We do not account for the emissions generated from the use of ICT to facilitate virtual visits. There is currently a dearth of data on the length of virtual visits—a metric needed to establish ICT emissions. Preliminary analysis using estimated visit lengths indicates that ICT-generated emissions from virtual care are negligible but given distinctions in the composition of provincial energy grids, ICT emissions will be higher (and therefore more relevant) in some provinces. Moreover, the balance between travel- and ICT-related emissions can be impacted by changing circumstances. On the one hand, as hybrid and electric vehicles make up a higher proportion of Canada’s cars, emission savings from avoided travel will diminish. On the other hand, “unless we specify lower carbon digital products and services…a rapid growth in data demand and digital equipment has the potential to add to [ICT] emissions²⁶.”

Second, our analysis also omits another factor that could reduce some of the carbon savings associated with virtual care: potential practice changes. Some providers have reported “overprescribing or increasing diagnostic testing to compensate for what they worried to be an incomplete assessment”—actions that would increase the carbon footprint of care²⁷.  These practice changes in response to the rapid uptick of virtual care during the COVID-19 pandemic are not yet well understood, and their implications for carbon emissions are therefore unclear. However, it is reasonable to assume that post-pandemic, as virtual care begins to be offered more discriminately for those appointments deemed appropriate, providers will feel less compelled to validate their assessments. This factor may therefore prove to be insignificant with respect to virtual care carbon accounting.  

Third, it is important to note that our figures for travel-related emission reductions are estimates only, which we have generated using self-reported data extrapolated to the Canadian population. Site and/or specialty-specific metrics related to virtual care could yield a clearer understanding of particular areas of opportunity to create and/or maintain virtual care services that maximize environmental savings (see Masino et al. 2010 for a rare Canadian study on virtual care’s environmental impacts). The ongoing collection of such metrics alongside data on health outcomes could also yield an understanding of virtual care’s longer-term environmental prospects, such as its potential to lead to decreased health care activity or smaller facilities with smaller environmental footprints.   

Finally, an additional consideration in efforts to reap all of the benefits of virtual care, including environmental benefits, is access. Ensuring that all Canadians have access to the ICT that facilitates virtual care, and that virtual care visits continue to be covered by provincial health insurance plans post-pandemic, are key elements in harnessing the promise of virtual care. 

Conclusion

The COVID-19 pandemic has accelerated the spread and use of virtual care across our health care system. There is growing expectation among Canadians for a digitally enabled, connected health care system, and as we teeter on the brink of returning to business-as-usual, Canada is at a critical inflection point where action must be taken to extend progress made during the pandemic into the future.

Dedicated efforts and investments are required to overcome existing technological, social and process barriers in the health care system to promote equitable and sustainable advancement of digital health solutions. In doing so, the many near and long-term benefits of virtual care can be more fully realized, including environmental benefits. Most immediately, virtual care solutions can help reduce patient, caregiver and provider travel, which has been identified as a key source of health sector emissions. Reduced emissions translate in the longer term to reduced negative health outcomes. Virtual care has the potential to further reduce emissions if improved access to care results in better health outcomes, preventing the need for future care. Furthermore, future health care facilities can be designed from the outset to provide care virtually, thereby decreasing their physical and environmental footprint.    

The environmental impact of virtual care is only one of many factors to consider when deciding whether to offer virtual care consults, in the case of health care providers, or to ask for a virtual consultation, in the case of a patient or caregiver. Not all health care can or should be delivered virtually. However, where it is a suitable option, a virtual visit is an opportunity to make a more environmentally sustainable choice that does not involve cost or sacrifice. More work is needed to fully understand the scenarios where virtual care can and should replace in-person care, as well as how to reduce barriers to access and optimize care delivery processes to maximize the environmental potential and many other benefits of virtual care. 

APPENDIX

Besides these environmental and public health damage metrics, we have also defined other intermediate output metrics:

• Total number of virtual care visits (TVCV), refers to the sum of the number of virtual care visits to a family doctor or regular place of care, the number of virtual visits to a specialist, and the number of virtual visits to a walk-in clinic or a general practitioner. The number of visits to a specific provider referred to the number of times a patient had seen the provider in the past 12 months through virtual means. These virtual means included videoconferencing, secure messaging and telephone. 

Along with these output metrics, we have defined several input metrics. They served as the main ingredients in the computation of the output metrics and included:

• Number of virtual care visits to a family doctor or regular place of care
• Number of virtual visits to a specialist
• Number of virtual visits to a walk-in clinic or a general practitioner
• Distance traveled by patients to visit their regular health care provider (HCP) or place of care
• Wait time (in minutes) in the waiting room at the regular HCP clinic (average reported by survey respondents)
• Travel time (in minutes) to visit the regular HCP (average reported by survey respondents)

These equations were used to generate extrapolated estimates for the intermediate output metrics: 

TVCV = Pop * v * pvv (1)

PTS    = TVCV * t      (2)

FCS    = TVCV * f      (4)

where Pop refers to the Canadian population aged 18 years or over; pvv denotes the share of virtual care visits in the total health care visits; v, t, d and f represent the average values derived from the survey sample respectively for virtual care visits, time spent on an in-person visit, distance traveled by patients to visit their regular HCP, and total financial costs saved. The average time spent on an in-person visit includes  the wait time in the waiting room at the clinic and the travel time  when visiting the regular HCP. Similarly, the average total financial costs saved encapsulates dependant care cost savings, income saved by not having to take time off work, and travel expenses.

To generate estimates for the environmental and public health damage metrics, we relied on these equations: 

CO2 emissions saved = TVCV * d * ε   (6)

SCC = CO2 emissions saved * a          (7)

DALYs = CO2 emissions saved * Ø      (9)

where ε is an emission factor for an average passenger vehicle. For one km traveled, the average emission was estimated at 0.2656 kgCO2eq/km [insert ref.]; a represents the monetary value (in terms of health damages) of one tonne of CO2 emitted in the atmosphere. This factor was estimated at $41 by Environment and Climate Change of Canada [insert ref.]; Ø is the loss of the equivalent of one year of full health associated with one tonne of CO2 emissions. We used a value of 6.96 * 10-4 DALYs [insert ref.].

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