Its recommendations call for a shift from a custodial to a stewardship model of data governance that would mandate the appropriate exchange and reuse of health Similarly, with the guidance of its Patient Voice advisory committee, the CMA has proposed a framework for a patient-partnered approach to health information governance (CMA 2022).

Jamieson and Zarn (2022) describe interoperability as the Achilles heel of digital health, noting the progress that the United States has been achieving. The Competition Bureau of Canada initiated a digital healthcare market study in 2020, and its first report addressed interoperability, including a call for electronic medical record vendors to comply with “anti-blocking” rules (Competition Bureau of Canada 2022). The federal, provincial and territorial privacy commissioners and ombudspersons with responsibility for privacy oversight recently called on all actors in the health sector to work in a concerted fashion to implement a “secure and interoperable digital health communication infrastructure” and set out roles and responsibilities for the parties (Office of the Privacy Commissioner of Canada 2022). Health Canada provided funding to the provinces and territories and Canada Health Infoway in 2020 to advance work on interoperability standards and related issues (Health Canada 2021), but it remains to be seen if the federal government will act on the PHAC expert group recommendations to address the unfinished business identified in this and other reports.

Appropriateness

Virtual care has stimulated interest in the appropriateness of virtual versus in-person care and the merits of telephone versus video-conference platforms. The Federation of Medical Regulatory Authorities of Canada (FMRAC) has developed model standards for virtual care, and several provincial and territorial medical regulators are making similar revisions to their policies (FMRAC 2022). In his 2021 paper, Falk called for specialty societies to develop specialty-specific guidelines, and the Canadian Medical Protective Association (CMPA) supports this call in a recent White Paper (CMPA 2022; Falk 2021). The Canadian Rheumatology Association took an interesting approach to this in its 2022 consensus statement (Barber et al. 2022). It classified seven reasons for the clinical encounter, ranging from reviewing test results to undifferentiated disease, and assessed them against clinical considerations, type of virtual care available and preference and access considerations. Segal et al. (2022) developed a framework for the appropriate use of virtual care in primary care that classifies care as either in-person optimal, virtual optimal or either mode acceptable depending on the clinical situation and contextual factors. More research is needed on the issue of telephone versus videoconference and on the appropriate role of asynchronous communication via secure e-mail or text.

Education

Issues of team-based care, digital health equity, data governance and appropriateness all need to be incorporated into health professional education. Kendall Ho (2022) puts forward well-rounded perspectives on education that focus on evidence, mentorship, professional culture and social accountability and calls for an all-inclusive stakeholder partnership. Interprofessional education should be emphasized going forward. 

Payment 

In the early days of the pandemic, governments introduced temporary fee-for-service (FFS) billing codes for virtual care provided over the telephone and via videoconference. Tharmalingham and Hagens (2022) note that as of May 2021, almost all physicians were providing virtual care over the telephone (93%), followed by videoconference (51%), e-mail and text messaging (36%) and remote patient monitoring (5%). A comparison to the 2020 experience of the US Kaiser Permanente health system suggests that there would be a much greater role for asynchronous virtual care in Canada if there was a payment mechanism for it. In 2021, Kaiser reported that 38% of their outpatient touches were done using secure e-mail – almost as many as the telephone (41%) and approaching double the proportion of office visits (21%) (Kaiser Permanente 2021). Bell and Chow (2022) also note the potential of remote patient monitoring and the need for a satisfactory funding model. In a study for Doctors Nova Scotia and the Nova Scotia Department of Health and Wellness, Deloitte recommended a stipend-based model to compensate physicians for asynchronous secure messaging (Deloitte 2022). More generally, the pandemic was certainly a disruptor to the long-established FFS model, and there is elevated interest in several jurisdictions in primary care capitation, but FFS is having a long goodbye. In 1999–2000, FFS accounted for 89% of physician clinical earnings in Canada; by 2009–2010, this figure dropped to 73% but has since stabilized at that level, reaching 72% in 2019–2020, and it will likely be around for a long time to come (CIHI 2021). 

Pan-Canadian Licensure 

Pan-Canadian licensure has long been a dream of physicians who want to do locums in the rural and remote parts of other jurisdictions, and virtual care has stimulated considerable interest. Falk (2022) lists several use cases for cross-border virtual care, and I would add specialized consulting services from academic centres. Cross-border virtual care is also an issue for disciplines such as psychology, physiotherapy and dietetics, just to name the ones that have come to my attention. Anderson (2022) underscores the potential of cross-border virtual care to leverage the small number of Indigenous clinicians to provide culturally and linguistically congruent care to Indigenous communities. Temporary arrangements were put in place early in the pandemic, mainly between the territories and neighbouring provinces. Since then, medical regulatory authorities have been revising their regulatory standards and policies, and two have made significant changes. The College of Physicians and Surgeons of Ontario (CPSO) has now put in place a requirement that physicians providing virtual care to patients located in Ontario must be licensed in Ontario, and the Northwest Territories (NWT) has amended its legislation to permit an out-of-territory licensed physician to provide virtual care to NWT residents if they have a referral from an NWT physician (CPSO 2022; Government of the Northwest Territories 2022). One of the issues – aside from accountability for quality of care – is that cross-border care also implicates issues of billing and credentialing/privileging (i.e., access to laboratory and diagnostic imaging services). Governments are starting to show interest more generally in cross-border licensure. Premiers raised the issue of health worker mobility at their July 2022 meeting and indicated that they would work with regulatory authorities to address this (Council of the Federation 2022). The Council of Atlantic Premiers recently wrote to its medical regulators to propose “a regional approach that would ensure physicians licensed in the region are able to practice in all Atlantic provinces without the need to acquire more than one license and pay additional licensing fees” (Houston 2022). Sweatman and colleagues (2022) reviewed models of licensure in sectors outside health to dispel the usual knee-jerk reaction that pan-Canadian medical licensure would require a constitutional amendment. 

Conclusion 

As I monitor the developments in virtual care, it seems to me that we have no idea just how good and useful the technologies of virtual care and information systems are going to get. As Anderson (2022) noted, any medical device that can be attached to a computer can be incorporated into a virtual care program. To cite one example, Myers et al. (2017) reported on the promising results of a touch-capable technology that enabled a patient’s own hands to serve as remote surrogates for the physician’s in the screening of acute abdominal pain. The growing pains and reservations about virtual care that we see now remind me of Amara’s law, attributed to 1960s computer scientist Roy Amara, who said that we tend to overestimate the impact of a new technology in the short run but underestimate it in the long run.