Canadian physicians’ perceptions on their use of and experience with virtual care offer important insights into finding the right balance in virtual care. Using data from the 2021 National Survey of Canadian Physicians conducted by Canada Health Infoway and the Canadian Medical Association (Canada Health Infoway and CMA 2021), we explored the mix of virtual care use by physicians, satisfaction with and challenges of virtual care and other perspectives around its continued use. We discuss how these data inform and enrich some of the key recommendations put forward by Falk (2022) in this issue. 

Background

Questions about digital health in general have been posed to physicians regularly over the past decade, through initiatives such as the Commonwealth Fund’s International Health Policy Surveys as well as national and provincial physician surveys. Between April and May 2021, the Canadian Medical Association (CMA) and Canada Health Infoway (Infoway) jointly conducted a national survey of physicians to better understand their use of virtual care. We heard from 2,071 Canadian physicians (1,000 general practitioners [GPs]/ family medicine [FM] physicians, 973 specialists, 98 residents) (Canada Health Infoway and CMA 2021). In our commentary, we describe physicians’ use of, experience with and perceptions of virtual care more than a year into the COVID-19 pandemic. We use these data to consider the recommendations presented by Falk (2022) and seek to provide additional insights into finding the right balance of virtual care in the Canadian healthcare system. Canadians’ experiences with virtual care are also available through Infoway’s annual Canadian Digital Health Survey (Canada Health Infoway 2021b). Combined, these data offer insights that enrich our understanding of the evolution of virtual care in Canada. 

Mix of Care Modalities Used by Physicians

Ninety-four percent of the physicians surveyed indicated that they provide care virtually but through a mix of modalities (Figure 1). Nearly all physicians (93%) provide care through telephone, half (51%) use video and over a third (36%) use e-mail and messaging. Only 5% of physicians reported using remote patient monitoring. Virtual care use is higher among GPs (98%) compared to specialists (91%). However, video visits are used by more specialists (58%) than GPs (44%), whereas e-mail/messaging is used by far more GPs (45%) than specialists (27%). 

Although virtual care has become an indispensable tool for physicians, in-person visits remain the most common form of consultation (Figure 2). Physicians reported that half (49%) of their patient visits on average are in person and the other half occur by virtual means, with variations depending on physician specialty and practice setting. GPs see a greater proportion (48%) of patients by phone compared to specialists (30%), whereas specialists see more patients in person and on video. 

Taking a deeper look at the proportion of in-person visits estimated by physicians (Table 1), we noted that significant cohorts of the physician group practise largely virtually or largely in person. About 30% of physicians reported that < 25% of their patient visits are in person, in contrast to 25% of physicians reporting that more than three-quarters of their patient visits are in person. 

Among primary care physicians (GPs/FM physicians), there is variability seen around practising virtually or in person depending on geography (Figure 3). On average, physicians in Alberta, Manitoba and Quebec estimate that more than 50% of their patient visits are in person, whereas in Ontario and British Columbia, physicians estimate that nearly two-thirds of their patient visits are virtual. 

Physician Perspectives on the Integration of Virtual Care in Practice

Physician satisfaction with the mix of virtual care modalities they use varies (Figure 4). Seven in 10 physician respondents were satisfied with telephone/video, and about 50% were satisfied with e-mail/messaging. However, about one in five physicians using each modality were dissatisfied with each virtual care option. 

The pandemic has illustrated that physicians and patients are adept at evolving and improving healthcare delivery. Nearly all (96%) physicians wanted to continue to provide virtual care but varied on whether they would increase (22%), maintain (42%) or decrease (32%) use. More than 70% of physicians reported that they have the knowledge and skills needed to use virtual care, are satisfied with the time spent with patients and found it easy to integrate virtual care into their workflow. Physicians reported benefits not only for themselves but also for their patients: 84% believe that virtual care improves patient access, and more than 70% believe that virtual care enables high-quality and efficient care for patients. 

However, integrating virtual care into their practice hasn’t been without challenges. Figure 5 summarizes areas of challenges experienced by physicians that are important to the dialogue around finding the right balance of virtual care. More than half of physicians identified important patient groups that may need additional supports to access virtual care (Figure 6). 

Discussion 

The findings we present in this commentary offer a snapshot of the physician experience during an important time of healthcare flux. With more than a year of experience with new virtual care tools, there is much to learn from the experiences physicians report to support best application of virtualization going forward. How do these data support or refute the recommendations in Falk (2022)? 

Recommendation 1, “Care is care,” (Falk 2022: 13), is supported by the evidence not only during the pandemic but even prior to it. Canadians have expressed an interest in care virtualization for over a decade, including majorities desiring the ability to view their data and engage with their clinicians through phone, messaging and e-mail (Canada Health Infoway 2021b). Physician delivery of telemedicine has steadily increased over 20 years, reaching more than a million encounters annually even before the pandemic (Canada Health Infoway 2020). Teleradiology transformed access to care for Canadians in remote locations (Canada Health Infoway 2011). Physicians’ sentiments reinforce patients’ sentiments that virtual care is here to stay. Infoway’s annual survey of Canadians in 2021 found that nearly half (46%) of all visits to a family physician in the past 12 months were conducted virtually (Canada Health Infoway 2021b). Nine in 10 respondents who had a virtual visit were satisfied with their visit, and 71% said that the personal connection with the healthcare provider was the same as an in-person visit. Overall, the survey responses indicated a demand for virtual care but also signalled that in-person care cannot be replaced by virtual means. 

Recommendation 2 calls for key health information to be “available in a usable digital format” (Falk 2022: 16). Although many core elements of patient summaries are now digitized and available to clinicians, our survey found significant gaps experienced by physicians: 78% reported access to results, but only 57% received discharge summaries for their patients and only 43% reported accessing patient information from external settings. Previous studies have indicated that integration, workflow and usability issues are major barriers and pointed to the critical importance of a “usable digital format” (Canada Health Infoway 2018). 

Our data do not provide insight into the most appropriate mix of virtual care modalities discussed in Recommendation 3 but do show a clear correlation between reimbursement and the use of and satisfaction with different modalities, with messaging and remote monitoring lower than phone and video use, which were more broadly reimbursed. Remuneration was a challenge identified by 39% of GPs. Physicians identified patients with low levels of technology literacy as the most in need of support to access virtual care, suggesting the need for modality flexibility.

The national survey of physicians contains many indications of the critical importance of Recommendation 6, which calls for “a new approach to clinical change management and medical education.” Figure 5 shows a wide range of challenges experienced by physicians related to virtual care. Although only 15% of physicians cited a lack of training on virtual care technology as a challenge, 43% reported challenges with maintaining appropriate boundaries with patients and 34% reported challenges with workflow. The variation in the use of virtual care presented in Table 1 cannot be fully explained by differences in patients and practices. Like other digital health tools, virtual care change supports the need to go beyond “How do I use it?” to “How does it fit into my practice?” Our data also revealed that although 87% of physicians use electronic medical records (EMRs), the more advanced functionality available in most EMRs has not been integrated into practice. For example, 49% of physicians reported using warnings for drug interactions, 27% use clinical decision support tools and 21% make an online booking platform available. These low levels of uptake are predictable as incentives, workflows, practice models and training have not adjusted to unlock the potential of digital health. 

Recommendation 7 states that “[e]quitable access must be a priority” (Falk 2022: 24). Figure 6 highlights six patient groups identified by over half of physician respondents as needing additional support to access virtual care. Technology literacy tops the list, supporting the focus on this recommendation. However, from language, to disability, to mental health concerns, the patients identified by physicians reflect a complex mix of barriers with significant impacts on equity. Digital health equity analysis from surveys of Canadians similarly shows that equity challenges are many and nuanced (Canada Health Infoway 2021a). Data have an important role to play in closing this gap as the broad consensus on the importance of equity needs to translate into tactics that address the specific gaps. In addressing language barriers, for example, virtualization of care offers a huge opportunity, but only if health systems are focused and purposeful in their actions. 

Finally, we see important variability in user experience across technologies, settings and geographies. Surveys of Canadians similarly show great variation in patient experience and that patients appear to value and benefit more from virtualization than physicians (Canada Health Infoway 2021b).

This variation reveals much about which solutions are most effective, which contexts are best and what kind of investments can generate the greatest value. We strongly support Recommendation 8, the prioritization of user experience. Efforts under way with the Canadian Institute for Health Information, Statistics Canada, Infoway and academia will advance this kind of measurement (CIHI 2022), but we suggest that many of the data needed to make more informed decisions, from policy to practice levels, are already available and should be more broadly used.

There is a physician and patient interest in continuing to provide care virtually. The recommendations in Falk (2022) are supported by our data and represent important steps to making the best use of virtual care tools going forward. Our data scratch the surface in identifying the many potential factors that might exist in striking the right balance between in-patient and virtual care and indicate that there are missing pieces that could fully inform this important policy discussion. Continued emphasis on research and knowledge translation is vital for virtual care and digital health broadly.

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