EMR Tips to Help you Resume Cancer Screening

By Nancy Gunn, Senior Advisor, EMR Lab, OntarioMD; Reza Talebi, Manager, Practice Enhancement, OntarioMD; Melissa Coulson, Director, Program Design and Implementation, Cancer Screening, Ontario Health (Cancer Care Ontario); 

In follow up to the blog on Resuming Cancer Screening During COVID-19we want to make sure it’s easy for you to identify higher-priority patients for cancer screening in your electronic medical record (EMR) systems. Ontario Health (Cancer Care Ontario) and OntarioMD have worked together to give you some EMR tips to help you start to screen your patients again for cancer.  

Preventative Care Queries and Searches 

  • To review Ontario Health (Cancer Care Ontario) Screening Guidelines click here
  • Use your current Preventative Care Queries and Searches to pull up a list of active patients in need of cancer screening. Once you have your list, use the columns provided to sort the patient lists or if your EMR has the functionality, you can export your report to CSV format for sorting and filtering.   
  • For example, you could sort your breast cancer screening list by people who have never been screened.   
  • Don’t forget! Check your flagged patients (using reminders, ticklers, alerts) to see who is due for annual breast or cervical screening because these patients may not appear in your regular preventative screening searches. 

For users of OntarioMD’s i4C Dashboard 

  • Use the Prevention Screening Dashboard, and the Colorectal, Cervical and Breast Cancer Screening tiles to identify patients.  
  • Click on Overdue Pie Slices to identify lists of patients who are due for cancer screening. 

TELUS PS Suite 

  • Filter based on the new guidelines for prioritizing testing: Open Records> Patient> Search> Select your current Cancer Screening Searches> click on the appropriate column names.  
  • Or you can use the Preventative Care Summary Report to find patients: Open Records> Patient> Preventative Care Summary Report> Uncheck Include Rostered Patients Only> double click on the Preventative Care Screening you want to work with (e.g., Stool Occult Blood- Not Done).  
  • Once you have your patient list, you can click on the column names to filter based on the guidance provided for prioritizing testing.   
  • You can also export these reports to CSV and filter by multiple columns. To export, click on Reports> Utilities> save as tab delimited or save as CSV.  

QHR Accuro 

  • In QHR Accuro click on Icon at bottom left hand corner > type the word Query into the search field> click on selection Query Builder to open> select your currently used Cancer Screening Alert Definitions (queries)> click on the appropriate column names to filter based on the guidance provided for prioritizing testing.  
  • To export reports after running queries, click the Export button at the bottom of the Results window. 

OSCAR EMR 

  • Go to Report> #13 Ontario Prevention Report> select Patient Set according to cancer screening> select the Prevention Query to match> Submit Query> click on the appropriate column names to filter based on the new guidelines for prioritizing testing. NOTE: These steps will give you the report for rostered patients only. To get a report for all active patients you must create a new Patient Set.  
  • The Ontario Prevention Report is not exportable. However, you can export search results generated through Report By Template searches. 

If you want help developing preventative care tools and searches, feel free to contact your vendor or OntarioMD i4C Advisory Service at support@ontariomd.com.  

Digital Health Week

by Sarah Hutchison, Chief Executive Officer, OntarioMD

OntarioMD CEO, Sarah Hutchison with her thoughts on Digital Health Week

For many of us in the industry, Digital Health Week is the time of year when we reflect on the impact of health technology.  This year we are simply marveling at the rapid transformation of health care delivery that has been enabled by technology in response to the global pandemic.   

Like you, we could not have imagined how COVID-19 would reshape health care.  

In just eight months, it feels as though we’ve changed almost everything about the way we work, and collectively we have demonstrated a receptivity to change at a pace – and at an intensity – we could not have dreamed of at the start of 2020. 

Health care delivery persevered through the most challenging public health crisis of our time, a credit to the ingenuity and resilience of those who work across the system – including the cutting edge and adaptive technology we are creating and implementing to support care.   

Clinicians have been at the forefront of digital transformation. Their practices have embraced digital and virtual care and, as they say, there is no going back.  These clinicians are now engaging with their patients using a range of virtual tools that video consults remote monitoring, secure messaging, online bookings and prescriptions delivered electronically.  

You can find out more about how we are using virtual care tools in a clinical setting, by visiting OntarioMD’s microsite created this spring to provide tips on how to screen patients virtually, how to keep in contact with those who are symptomatic, and how to virtually help patients with other conditions including chronic disease and acute illness.  

Virtual care opens up a whole new world of opportunities for patient care, and it also raises new challenges that need our attention.  These include how patient care can be delivered so that that health information is not siloed, what encounters and circumstances are most appropriate for virtual care delivery and how we manage care across provinces.  We are also mindful to the impact of technology and change on providers and patients alike – seeking to reduce physician burnout.  Many of these timely topics were explored at OntarioMD’s first Virtual Care Day Conference in October, and for those who missed it livestreams of those sessions can be found here. 

Ontario hospitals are tapping into digital health technology to connect to family doctors as part of their role in the rapid delivery of COVID-19 test results and patient encounters related to the virus to help stop the spread of the coronavirus and ensure follow-up care for patients who contract it.  Reports from hospitals and their COVID-19 assessment centres are being transmitted instantaneously to primary care clinicians’ Electronic Medical Records (EMRs) as a result of an adaptation developed with Ontario Health – Digital Services and vendor partners to OntarioMD’s Health Report Manager (HRM®). 

This is a digital solution to a pressing need that has meant physicians and nurse practitioners are receiving instantaneous notices that COVID-19 test results involving their patients are available through the province’s Ontario Laboratories Information System (OLIS).  

We believe digital innovation can power a healthier Canada.  That’s why we’re driving and enabling innovation in health care, developing an ever-expanding portfolio of digital health tools and services that allow clinicians to practice efficiently and connect to systems across health care in real time. Our products help clinicians improve the patient experience while providing significant cost savings to health care delivery. 

Today, more than 20,000 Ontario clinicians have adopted EMRs and additional award-winning digital products connected to them developed by OntarioMD.  

For example, through Health Report Manager, clinicians using an OntarioMD-certified EMR can securely receive electronic patient reports from hospitals and speciality clinics directly into patients’ charts, eliminating paper, saving time, and most importantly, enabling faster follow up with patients to reduce complications and hospital readmissions.  

And the Insights4Care Dashboard is an EMR-integrated population health management tool that provides insights about patients at a glance to help turn data into better outcomes through preventative care and better management of chronic illnesses. 

Through EMR-integrated eConsult, clinicians can get timely access to the advice of specialists within their EMR, which may result in a timely referral or prevent an unnecessary one.  

With digital tools, of course, come privacy and security issues. OntarioMD offers training, tools and resources to ensure physicians understand their role as health information custodians and can put in the safeguards to treat patient data securely and help prevent breaches.  

Our services are in demand as more and more clinicians look for digital solutions, products and services that enhance patient care, and we are in discussions to expand some of our services to other jurisdictions as a result. 

Only a decade ago, physicians had to rely on fax machines and the postal service to learn that their patient had been discharged from hospital. 

Today, patient information from more than 500 hospital and specialty clinic sites are delivered to the EMRs of more than 11,000 clinicians across Ontario. Through HRM, more than 70 million reports have been delivered digitally – that’s more than two million reports every month.  

Technology has moved the dial in health care delivery, this year, and it will continue to drive transformation over time. I can hardly wait to see what next year brings. 

To find out more about OntarioMD’s suite of digital health tools, visit OntarioMD’s website at www.ontariomd.ca, or contact us at support@ontariomd.com

#thinkdigitalhealth

Resuming Cancer Screening During COVID-19

By Aisha K. Lofters MD PhD CCFP Family Physician, Women’s College Hospital Family Practice Health Centre; Associate Professor and Clinician Scientist, Department of Family and Community Medicine, University of Toronto; Chair in Implementation Science, Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital 

Ontario’s health care system has been significantly impacted by COVID-19 and these impacts will be felt for a while. At Ontario Health (Cancer Care Ontario), we paused cancer screening back in March as a result of the pandemic, but we recently provided guidance on gradually starting up breast, colorectal and cervical screening. Because COVID-19 is affecting health system capacity differently across Ontario, here are some tips based on this guidance to help you make decisions about when to screen your patients in the coming months.  

Breast Screening  

Screening at Ontario Breast Screening Program (OBSP) sites is gradually beginning again. Each site is resuming based on local factors, such as availability of personal protective equipment, staffing, physical space and local COVID-19 infection trends.   

If capacity is limited in your area, here are some tips on who to send for breast screening: 

  • High Risk OBSP participants 
  • Average risk initial screens 
  • Average risk one year rescreens  

Our website has more information on the current breast cancer screening guidelines.  

Cervical Screening 

If someone comes to your office and they are due for cervical screening, we suggest screening them. Annual screening for people at elevated risk for cervical cancer should also start up again as you begin to have in-person appointments. Examples of people at elevated risk include anyone who is:  

  • Discharged from colposcopy with persistent low-grade cytology 
  • Discharged from colposcopy with an HPV-positive test and a normal or low-grade cytology 
  • Immunocompromised 

In addition, colposcopy services are gradually resuming. To make sure people at the highest risk for cervical cancer are able to get a colposcopy appointment during COVID-19, we recommend only sending patients with a single high grade cytologic abnormality (e.g., HSIL+, AIS) or two consecutive low grade cytologic abnormalities (e.g., LSIL, ASCUS). Patients with a single low grade cytologic abnormality should be re-screened in primary care in approximately 12 months with cytology.  

As a reminder, any patient who is positive for human papillomavirus (HPV) strains 16 or 18 should be referred to colposcopy regardless of cytology result. 

Visit our website to find out more about the current cervical screening recommendations.  

Colorectal Cancer Screening  

As of October 20, 2020, screening with the fecal immunochemical test (FIT) has been expanded to all eligible people at average risk for colorectal cancer. Since ongoing fluctuations in COVID-19 cases and local variation in COVID-19 trends are expected, consider local trends in COVID-19 transmission and local capacity for diagnostic services (e.g., colonoscopy) prior to initiating colorectal cancer screening. If you have limited capacity for screening, we recommend focusing your screening efforts on people over the age of 60. 

Because of COVID-19 safety precautions and potential delays with the mail, there may be delays in getting a FIT kit. 

Here are some tips for sending in requisitions to prevent further delays: 

  • Please do not batch fax requisitions as this can lead to errors and subsequent delays 
  • Include a valid OHIP number with updated version code 
  • Ensure that your patient’s mailing address information is correct  
  • Do not send repeat orders until at least 4 to 6 weeks have passed to allow for processing and mailing time 

You should also resume referrals to colonoscopy, especially for patients with an abnormal FIT result, patients who are at increased risk for colorectal cancer, or patients who are eligible for post-polypectomy surveillance with colonoscopy. You can find out more about the current colorectal cancer screening recommendations on our website

This guidance is based on the best available evidence and we hope you find it helpful. Please contact us if you have any questions at cancerinfo@ontariohealth.ca.  

OntarioMD expanding virtual events, as first virtual conference breaks participation records

by Sarah Hutchison, Chief Executive Officer, OntarioMD

OntarioMD’s first Digital Health and Virtual Care Day was a huge success, with more than 3,000 engaged attendees from around the globe engaging virtually in a series of high-value sessions about the future of Digital Health. 

Topics encompassed everything from practical pointers on virtual care, to the latest know-how on virtual billing, and a demonstration on how to improve population health data using the EMR-enabled tool Insights4Care. 

For those who may have missed it, recordings of the keynotes and information sessions can be viewed on the conference page of OntarioMD.ca at https://ontariomd.live/live-streams

It was the first time since our annual showcase conference was launched as the EMR: Every Step Conference in 2012 that it was entirely virtual and, judging by the response, virtual events as well as virtual care – will transform the future of our engagement.   

We surpassed the previous attendance records of our former in-person conference and attracted participation from 22 countries.  This event maintains its position as Canada’s largest clinician-centred digital health learning and networking conference series. 

Participants, including clinicians, system stakeholders and vendors, began the day with keynote addresses by Matt Anderson, President and CEO of Ontario Health, and former federal health minister Dr. Jane Philpott, now special advisor to the Ontario Government on the new Ontario Health Data Platform (OHDP). 

Our keynote speakers reinforced the idea that successful delivery of all aspects of our complex health care system — from the local patient-centred care overseen by the Ontario Health Teams (OHTs) to the linking of health data to improve clinical research — is dependent on the evolution of digital solutions. 

Dr. Philpott told us the pandemic has propelled the health care system and those who work within it to do things in virtual care delivery and remote care that we have wanted to do for decades, and that this has resulted in even more benefit for patients.  But the pandemic has also revealed cracks in the digital health landscape, she said, including a lack of uniformity in data standards across provinces, and across Canada.  

Philpott said the Premier’s Office in Ontario has issued several “challenge questions,” for the OHDP, using big data to answer questions about pandemic issues including vaccine rollout, containment strategies, health system resources, and vulnerable populations and health equity. The project will result in the largest collection of health data in Canada. 

Mr. Anderson cautioned that Ontario’s health funding infrastructure needs to change alongside transformations of the health care system to ensure that resources are in alignment with the more integrated systems we are creating through the use of digital technologies. 

This virtual event has laid the groundwork for the future as OntarioMD works to connect systems, clinicians and providers and deliver helpful guidance and thought leadership in our increasingly complex and evolving health care system.  With the positive feedback on this conference, we will continue to focus on delivering content that is relevant to our participants.  OntarioMD has more virtual learning planned throughout the year to be conducted by our knowledgeable staff or our Peer Leaders, who are digital health experts and early adopters of virtual care tools.  

Whether in person, or virtually, we look forward to connecting with you all again at next year’s conference, sharing more ideas, and hearing new perspectives on the future of digital and virtual health care.   

We want to keep the dialogue on digital health and virtual care going throughout the year. Let us know which topics you would find most valuable for your patients or your practice by sending ideas to info@ontariomd.com or in the comment field below. Advice with digital health systems, virtual care tools or your EMR, is always available by requesting support from support@ontariomd.com.  

OntarioMD is here for you! 

The Culture of Curiosity in Family Medicine

by Dr. Michelle Greiver

I would like to thank OntarioMD and the OMA Section of General and Family Practice for allowing me to provide some periodic reflections during this Annus Horribilis. I am a community-based family physician and have been doing Practical Research in Family Medicine for the past 20 years. 

This started with a patient on a Friday afternoon 20 years ago.  He had chest pain and I was not sure what investigations were best for him. I found some guidelines, but they were long, specialist driven and hard to apply in my small practice. There had to be a better way.

I had recently bought a PDA (Personal Digital Assistant), a small handheld computer which was a precursor to smart phones during the Jurassic Period.  I thought I would program the guideline for the PDA so it would help me with what to do. The next question was:  would this help anyone else? I got some help from Academics and we ran a randomized controlled trial; I asked friends and colleagues to participate. Half the family physicians were randomly chosen to receive a PDA with my program and the other half continued with usual care. Physicians in the second group were not too happy with me because they did not get a PDA. The result:  https://www.cfp.ca/content/51/3/382

I was now curious about many other things in my practice, which has led to no end of trouble.

I started using an EMR in my practice in 2006 and documented the journey at https://drgreiver.blogspot.com. I thought EMRs would improve the care I provided to my patients — I was very sure care would be better and was determined to use scientific methods to prove this to everyone.

I compared preventive services for a group of colleagues implementing EMRs and a group continuing to use paper records. I looked at influenza vaccinations, Pap tests, colorectal cancer screening tests and mammograms. Much to my dismay, there was absolutely no difference. To my even greater dismay, the study won the 2012 Canadian Family Physician Best Original Research Article award. I also ran focus groups to find out what my colleagues thought of their EMRs; there were many complaints about unexpected costs, software problems, computer crashes and lack of ongoing training to enable more advanced use.

Have things changed? Efforts at OntarioMD and by many physicians to improve the way we use EMRs are likely making a difference. Perhaps I should re-do my study and revisit my conclusions! 

The curiosity has led me to think about more uses of EMR data, and this resulted in participation and leadership in our Practice Based Networks (see for example, UTOPIAN), more Quality Improvement activities and many research projects. My life became enormously enriched by working with many smart, innovative, and interesting people; my friend Dr. Darren Larsen tells me that I do a great job finding potential collaborative partnerships.    

Here is another example of a project that came out of conversations with colleagues. Have you ever been curious about the number of medications we prescribe to our seniors? About one in four Seniors across Canada are on 10 or more medication classes! Using UTOPIAN EMR data, we found that each family physician looks after, on average, 24 older patients that were prescribed 10 or more different medications in the past year. 

Can we do something about this? My colleagues across several Learning Networks have partnered with family physicians and their practices across Canada. We think that audit and feedback with EMR data, practice coaches and Learning Collaboratives to share innovations with each other can help family physicians as they deprescribe drugs like benzodiazepines or antipsychotics for our elders taking many other meds. This could make a difference to seniors’ health and lives:  fewer falls, less risk of admission to Long-Term Care. We are testing this in a randomized controlled trial which received $2.6 Million in funding; please see https://www.spiderdeprescribing.com/

Now I need your help.

We can only understand the impact of COVID-19 on our practices and our patients through collecting and analyzing health data — the stories of patients seen in our practices need to be heard.  The pandemic has exposed many data gaps in Ontario. Family doctors are vitally important to ensure our data are included, as our information reflects our settings, patients and communities. Collectively, family medicine’s voice can be heard through providing safe and secure access to real-world data. This is possible with your help.

By agreeing to supply data through our practice networks, you contribute to a secure provincial base of evidence that will strengthen family medicine’s capacity to learn about this pandemic and prepare for the next one. This includes effects on preventive services, chronic disease management and long-term outcomes for our patients. For more than 10 years, we have been safely and securely collecting EMR data from practices of consenting family physicians, with full privacy protection, to study and promote the vital work done in family practices. The data can be used to help make the case for the importance of investing in family medicine.

The time and effort it takes to participate is minimal:  all you have to do is fill out a consent form and a brief survey; our staff will co-ordinate data extraction at your practice, with all safeguards in place.

Please help us to build practical evidence in family medicine, by supporting our collective Culture of Curiosity and by contributing data to our Practice Learning Networks. The time and effort it takes to safely and securely contribute is minimal; please see https://www.dfcm.utoronto.ca/contribute-emr-data.

Michelle Greiver MD, MSc, CCFP, FCFP. Gordon F. Cheesbrough Chair in Family and Community Medicine, North York General Hospital. Director | University of Toronto Practice-Based Research Network (UTOPIAN). Associate Professor, Department of Family and Community Medicine, University of Toronto. Lead – Digital Health for Research and Care, Diabetes Action Canada. Adjunct Scientist, ICES

Planning OntarioMD Digital Health and Virtual Care Day

by Revin Samuel, Event Manager, OntarioMD

Like a lot of conference planners out there, when the pandemic hit, the scope of my job changed forever. Transitioning to virtual conferences has been an adventure to say the least. Sure, you remove the venue space and the catering and the detailed registration process, but you become more reliant on technology than ever before and you need to understand that technology, and appreciate it for what it can and cannot do.  

OntarioMD Digital Health and Virtual Care Day is scheduled for this coming Thursday, October 1. This is my first venture into a virtual conference, and for a first one, we decided to really go big! It has been a tremendous learning experience for me personally in trying to learn the technology, grasp all the little details that need to go into planning a virtual conference from detailed run sheets to multiple dry runs and dress rehearsals. It is an incredible team effort, which involves different experts owning different elements of the event.

The biggest conference I would plan for an in-person conference would be our EMR: Every Step Conference, which I have been doing since 2012. We’ve almost had up to a 1000 people attend that conference at it’s peak and so the vision for a virtual conference…take that type of format, make it virtual, add in the fact that nobody has to travel, and your audience scope is going to seriously expand!

We have 2300+ registered participants – our largest number to date for an OntarioMD conference! Our team has put a lot of effort and planning into this, to provide an event that helps the digital health community and clinicians get inspired, motivated, and learning more about digital health and virtual care tools.

Do not forget the virtual tradeshow. This is another pilot initiative for me, and I have already got ideas in my head about how to improve upon it in the future. The details and logistics going in to setting up customized booths for each vendor can get pretty complex and thanks to our internal resources at OntarioMD, we are hopefully able to pull it off.

Attendees can expect the same quality educational experience as our award-winning in-person EMR: Every Step Conferences have offered over the years. The event will feature keynote addresses, from Dr. Jane Philpott, and Matt Anderson, President of Ontario Health. We will also offer three streams of concurrent live sessions, with five sessions in each stream. The afternoon will include 20 EMR virtual workshops with OntarioMD Peer Leaders, where we will leverage 40 of our internal staff to manage each of the 20 virtual rooms. These workshops provide an opportunity for EMR experts to help their colleagues enhance their use of the EMR and other virtual care tools.

Each live stream we run is considered an event and runs live for up to 3.5 hours and we are running five live events. This involves a moderator, a lead producer, another producer and two people to manage questions and the live chat plus a lot of time management skills to make sure each session starts, ends on time and the stream goes according to plan. It takes a team to do this and everyone is a backup for someone else, you need contingencies!

With that in mind, it makes your agenda a lot tighter, but you are truly getting quality over quantity. This year’s conference features 10 educational sessions with some tremendous speakers. View the agenda here

You can find out more about the conference and register for free by visiting www.ontariomd.live where the conference will be hosted. This site has been developed with tremendous precision and effort in-house and contains the agenda, support options, all of the live streams and a virtual tradeshow.

While a virtual conference of this size and magnitude might normally be outsourced to a third-party platform, our tech-savvy OntarioMD team elected to come together and pull this off using internal resources and knowledge. This will involve the support of the majority of our organization (over 60 staff members) and has required over 35 dry runs and dress rehearsals to ensure the technology works and plan contingencies for things that could go wrong.

With any pilot initiative comes risks and challenges. We don’t anticipate that it will all be smooth sailing, and there will be many lessons learned. But we do hope this is a great step forward for OntarioMD and that everyone who attends learns something new.

Register for free at www.ontariomd.live and we’ll see you this Thursday, October 1! 

Are we using EMRs to their fullest potential?

Written by Dr. Darren Larsen, Chief Medical Officer, OntarioMD

So we use our EMRs every day for every aspect of care. We bought them, we trained on them, we became moderately proficient, but then what? As experienced EMR users and skilled clinicians, how far did we go beyond that? Are we using EMRs to their fullest potential? Do we understand all the opportunities to do more with the data we produce? Do we see beyond record keeping? Have we automated workflows wherever possible to make our lives easier?

At OntarioMD, it is our business to know and help you find out as well. Seven years ago, a maturity model for measuring EMR use was created. The EMR Maturity Model (EMM) was tested and compared to other similar models such as the HIMSS EMRAM tool. It was put in the hands of EMR expert users. It was re-written and expanded to be relevant to daily community practice. It was also converted to a self-administered online tool, now known as the EMR Progress Assessment (EPA). The EPA was Ontario born, but now is used by other provinces as well to measure effective use of their same EMR systems.

Despite the clinical validity of the tool after years of use and its practical nature, the model itself had never been scientifically tested. We thought it should be subject to the same academic standards as other measurements. So, we asked such questions as: what does the tool actually measure? How well does it measure it?

We engaged in a systematic process of validating the EMM via statistical tests of validity and reliability on the data collected by the EPA tool. This study was recently published in the International Journal of Medical Informatics. Here’s what we learned:

  1. We measure one major thing well – EMR maturity! This means that, when you take the EMR Progress Assessment, you can be confident that your results are a sign of whether or not there is more of your EMR you could use. It can point you to areas you might want to expand or improve on. It can prompt thoughts about quality and efficiency.
  2. Measures are consistent across the list on how we measure maturity.  They line up so that a level 3 is the same level 3 over time and across clinicians.
  3. Maturity is not an indicator of performance. Using an EMR for good proficiency in care gets us to the maturity level of just over level 2. We can be great clinicians, but never move higher than that level.  Beyond level 2 is more about how the practice’s EMR is used within the larger health system. It involves system integration. It revolves around data. A fully integrated system and standardized, high quality data are super helpful when you’re trying to do the most with your practice in designing care for populations.

If you are a clinician who wants to know more about your EMR use, as well as wants to carry your practice further into automation, integration and use of data, then an EPA is a great place to start. You can take the complete survey in about 20 minutes. You will not only learn where you are in terms of EMR proficiency, but also be able to compare your level according to the EMM with where you want to be. And then you can drive out a plan of attack. And there is help. OntarioMD can move your practice ahead exactly the way you want it to be moved.

When Virtual Reality Becomes Reality

Written by Ashok Bhattacharya M.D., FRCP(C)

March 23 2020, 1:00pm

I was sitting across from my patient watching the words escape from her mouth as she inspired to make them. Then she exhaled…no mask, no gloves, no gowns. I was more than 6 feet from her face. I was listening, I really was, but there was something in the back of my mind. What if she has COVID? I was ‘wiping down,’ and had a few bottles of Purell salvaged from the box the Ministry of Health sent during the 2003 SARS crisis. I felt like a lonely soldier, low on ammunition, nervously defending a post as the enemy closes in. I couldn’t see or hear this foe—I could feel it. I should stay…but should I run? Dedicated doctors often suffer from presenteeism. I stayed.

The Practice

I have been practicing psychotherapy since 1986. I graduated in 1989 from the University of Toronto in the specialty of Psychiatry. The 1980’s marked the end of the dominance of psychoanalytic theory and the explosive beginnings of the biological revolution spearheaded by Prozac. For the first time, patients were asking to be placed on an anti-depressant: an SSRI. The arm-twisting efforts to encourage compliance with the tricyclic antidepressants were antiquated.  The vicissitudes of the mind had become the chemicals of the brain.

Setting up my practice was easy; I just opened the doors to my moonlighting practice a little wider. In two weeks, I was full and had more referrals than I could cope with. I started out doing 60-hour weeks. I know, this is a recipe for burnout. Since 2014, I have been presenting at conferences on the topic of burnout. By the time COVID-19 hit, my regular caseload was 45 hours a week. I see a lot of couples [Oakville has a high divorce rate], victims of PTSD, and depressed/anxious clients raging in age from 20-80 years old.  Being a psychiatrist is the only career I seriously considered. It’s the only reason I went to medical school. I love my job. I know that sounds cliché, but it never ceases to amaze me how you can aid a person by assisting them to alter their narrative. Yes, I am a psychotherapist at heart.

March 26 2020, 6:00pm

My patient emailed me, “I have a high fever and a cough.” She’d been tested. “I won’t know the result for a week.” My denial crumbled like a wall of salt being hit by a tidal wave. I realized my post was already surrounded, I had run out of ammunition, and the invisible enemy was here. “Scotty, beam me up!” There was no Scotty; there was virtual care. That was the last time I saw a patient in my office. I was scared, and I felt like a fool. I had put myself in this place. I’m the doctor! How could I put my patients and myself at risk? I felt shame. (Her test was negative. I’d dodged a bullet.).

Virtual Platforms

I applied to OTN to use the site to conduct eVisits with my patients. On March 23 2020, I downloaded Doxy.me, one of the virtual care tools curated by OntarioMD on OntarioMD.News. Luckily, my tech-savvy daughter was visiting, so she could help her old dad with the inevitable stupefying moments of learning a new computer technology. Incidentally, she lives in Italy and was stuck in Ontario during Italy’s worst times with COVID. She has since managed to return to Italy safely.

The Learning Curve

I was one of those ignorant die-hard believers in face-to-face therapy. Previously, if someone told me they had a ‘virtual session,’ I dismissed it as an irrelevant experience that couldn’t possibly replace a three dimensional ‘in the room’ session. I was utterly and completely wrong. The virtual experience became easy once the technology became familiar.

Advantages of Virtual Care

  • Patients can see me in the comfortable surroundings of their home. They are more relaxed, they haven’t had to commute, they don’t need to find a parking spot, and are ready for the session immediately.
  • Patients seem more motivated; like me, they have to work a little harder to make an impression on a little screen. It captivates them. They are also less intimidated by the ‘doctor’s office’ vibe. Their waiting room is their own familiar surroundings. They don’t have to spend their time reading out of date magazines in a waiting room full of sniffles.
  • Since TV, we have become used to learning from a screen. It’s a great teaching tool, and I have developed many props that make explaining things much faster. It’s as if you are the presenter and PowerPoint slide in one.
  • Sessions are much easier to close especially for the ‘sticky patient’ who has trouble with the session ending.
  • In a normal office visit, you see the patient and they see you. In a virtual session, you can see yourself, how you come across, and your facial expressions. Finally, you can see what your patient is seeing. Initially, it was a bit of a shocker. But like a golfer learning how to improve their swing, it’s very helpful to see yourself wind up and follow through from a third person perspective. In psychiatric training, you may watch a video of you interviewing, but with virtual care, you see yourself in real time. It has definitely improved my technique.
  • Face masks are a new reality for enclosed spaces. With virtual care I can see my patient’s face, and they can see mine. I can’t imagine someone crying vigorously while wearing a mask.
  • If direct physical procedures are not required, virtual care is the pinnacle of physically distanced medical care during a pandemic caused by an infectious agent.
  • Thankfully, it doesn’t come up often, but physician safety—especially when you’re alone in an office with a volatile, or dangerous patient—is much less of a worry with virtual care.

Disadvantages of Virtual Care

  • With some patients, especially those who live in close quarters, privacy has been a problem. They may take the call in their car, garage, bathroom, or behind a tree in their backyard. My office is very private and those clients prefer that environment.
  • Virtual platforms require solid Internet connections. Drops and disconnections do occur. I simply advise my patients at the beginning of the session that if we get cut off, we may have to use the telephone to continue the session. Luckily, this rarely happens.
  • Virtual care cannot replace direct patient contact for many necessary medical procedures at least with the present technology.

A Success Story with Virtual Care

My patients who suffer from Post Traumatic Stress Disorder (PTSD) are all doing better. Initially, I didn’t know why. I think the physical separation and the virtual distanced format make them more comfortable, less triggered, more grounded, and able to focus on the psychological effects of their trauma. We can get to those psychological issues faster and achieve a deeper quality in the work. Therapeutic progress seems to be occurring twice as fast as office-based care. Interestingly, the men appear to be benefitting more from the virtual experience than the women. I think men are more comfortable sharing their feelings when they are not facing someone, especially another man. In office sessions, men don’t cry as much as women in therapy session. They do now in virtual care! Those patients have all asked me to see if we can continue with virtual care after the pandemic is over. I hope we can.

After an intense session with a patient with severe PTSD, I may worry about them getting home safely especially if they were very dissociated. That worry is gone. With virtual care I can quickly and easily check in with them and improve continuity of care. That ‘bridge’ between sessions is allowing the therapy to have a steadier flow. Patients are calmer and I feel more confident as a therapist.

Future Plans with Virtual Care

I am hoping that virtual care will be a substantial part of my psychiatric practice going forward. No more ‘snow days’, no more ‘empty hours,’ and a huge saving in time for patients with the elimination of transportation issues. As technology improves, I think this could surpass the ‘office visit’ as the gold standard for psychotherapeutic care.

It’s likely that there will be events in the future that will require us all to physically distance ourselves again. With a foundation of well-established virtual care, we will be ready to act immediately, and not be that lonely soldier standing guard in a battle that can’t be won. Virtual care is safe, easy, and the right thing to do.  

About the Author

Dr. Bhattacharya graduated from Memorial University Medical School in 1984. He completed his specialty training in Psychiatry at the University of Toronto. Since 1989, he has been in private practice as a psychotherapist for individuals and couples. He has been married for 33 years, has three adult children, bikes and runs, and writes, records, and performs musically.

He is the author of two books:

CAKE   A Guide to Reciprocal Empathy for Couples 2006

Deep Fried Nerves   A Study of Burnout in Doctors 2016

Virtual Care is Here to Stay – by Dr. Darren Larsen, Chief Medical Officer, OntarioMD

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The last four months have seen the rapid rise of the use of virtual care tools in practice.  This has been a remarkable change. Doctors went from about 7% use of virtual care to 89% of primary care physicians using a virtual care tool, and 80% of all visits happening virtually. Due to the rapid spread of the coronavirus pandemic, doctors and nurses went straight into problem-solving mode (which I am very proud of, I must say!) and changed the way we provide care almost overnight. Having said that, there are major gaps in care that we must get to very soon or the downstream effect will be a challenge.  Virtual care is here to stay. The horse is out of the barn and cannot really be corralled again, but some order needs to be applied to the current disarray.  Where do we need to direct our attention next? 

1) Provision of virtual care in some of our most challenging care environments:  long-term care and congregate housing like group homes for disabled adults, shelters, hospices, jails, etc., are perfect examples.  Some of these places have started to apply virtual care.  Many have not.  There needs to be a consistent approach to making sure location and living conditions are taken into account and prioritized. 

2) Many medical problems require examination and the laying of hands to diagnose or treat.  Paramount at this point in time is cancer screening, preventative health visits, palliative care, lung disease, neurological disorders.  How will we do better with virtual to get these programs up and running again?  We will have ago to rethink our processes.  Physical exams are still possible virtually, but they take on an entirely different form.  This will require retraining and knowledge transfer. 

3) We must focus on areas where inequity of care prevailed before COVID-19; remote communities with poor internet access, indigenous communities, homeless communities, refugees and recent immigrants are all at a disadvantage when it comes to high tech solutions like video visits.  The reasons are obvious.  They must be faced head on and planned for.  The approaches needed here will be different. 

4) Some high-risk areas are left behind: seniors care, the mental health system, and home care come to mind.  We must pay attention to these as they are ripe for care redesign and virtual care may actually be very impactful. 

5) Integration of products into the point of care is important. This largely does not happen now.  For this, we require APIs from EMRs and hospital information systems, rules allowing open data flow and a reduction of the competitive nature of the virtual care and data business.  We need a more unified approach focused on creative co-design and outcomes. 

6) Standards for virtual care tools are important now, and certification to these standards must follow to ensure safety. “Caveat emptor” thinking applied at the start of the pandemic crisis, but we are past that now. Security and privacy can and must be guaranteed.   

7) Attention to the blending of virtual and in-person care is needed.  We can never be permanently ”all virtual” or even “80% virtual”.  In a recent CMA survey, 60% of patients stated that they still want an in-person visit as the first option for their new problem  This is because we are human, and trust between humans evolves by looking into each other’s eyes, interpreting body language, and even holding a hand in tough times. This is important as the physician-patient relationship is special, and trust matters. 

OntarioMD is helping to lead the pace of change for clinicians in adopting virtual care.  We want to be there for you.  You are living the change and crafting your practice for excellence in real time.  We need your ideas about where your energy in making your technology life better is best spent.  I encourage you to bring them to us.  We are developing a plan for the future that responds to your practice needs.  Help us design it.  Reach out to me with ideas at darren.larsen@OntarioMD.com. 

Virtual Care Tips and Tricks

Contributors include OntarioMD Practice Advisor Tania Hunt with recommendations from OntarioMD Physician Peer Leaders from our Virtual Care Webinar Series

This is part two of our blog series on virtual care for clinicians. Check out part one on Virtual Care: Preparing your staff and notifying your patients here.

In part one, we discussed setting up your practice for a virtual care environment, preparing your staff and notifying patients. With your practice set to go, and everyone prepared, let’s review some of the different virtual care options you may wish to consider for your practice.

Telephone visits are the easiest virtual care platform for most practices and will be part of your virtual care toolkit. All patients have access to a phone and do not need any instructions on how to use it. Phone visits are quick to set up, and do not use internet bandwidth. Remember to always use a private number when calling patients that will not be visible on the phone’s call display. To maintain privacy on the patient’s end when you call, ask them if they are able to speak to you privately without being overheard.

It is important that your staff tell the patient that when you call at the agreed-upon time, their phone will display ‘unknown caller’ so the patient knows to answer the call. When speaking to a patient, always confirm the patient identity.

If the patient needs lab work/DI, determine if it is really necessary or if it can be delayed to limit the patient’s exposure during COVID-19. If you and the patient both feel it is absolutely necessary, have the patient follow up with a lab to schedule an appointment.

When it comes to other virtual platforms, if it is difficult for you, it will be difficult for the patient and you will become tech support for them so pick a platform that you and your team understand and can operate smoothly. Purchase necessary equipment such as back-up headsets with built in speakers and a desktop camera. If possible, work with two laptops, one with the EMR and the other with the video visit tool (OTN, etc.). If multiple screens are not an option, leverage your smart phone for the virtual visit and keep your computer for the EMR. Remember, for both phone and video visits, you will need the patient’s consent before you begin the visit. See part one of this blog series for how to obtain consent.

When you start the video visit, it is always reassuring for the patient  to have a quick scan of the room you are in so they see no one else is in the room while you communicate with them and their privacy is preserved. Ensure the patient’s privacy and security on their end as well. Ask questions like “Are you in a quiet room?” “Can you hear me properly?” “Is anyone else hearing this call?” “Do you feel safe having this discussion?” Look into the camera, not the screen, when asking questions. If a video visit does not work, revert to the telephone.

How can video visits be most helpful? They are especially valuable for patients with mental health issues. Connecting with them in their own home can be a more positive experience and put the patient at ease. Video visits are also helpful for patients with rashes, burns, cellulitis, etc. Use an app with imaging capabilities to capture an image of the patient’s issue for tracking and uploading to the patient chart for comparisons during future visits.

Video visits are a great way to learn more about patients by seeing their home, and meeting pets and family members. This will put patients at ease before you start the visit. Remember to always hang up the phone or disconnect the camera after a virtual visit. Turn the camera off when not using it or use a webcam blocker to avoid any unwanted visibility of your surroundings.

Be on time for your virtual appointments. The patient is not in the waiting room so they will not know if you have forgotten them or if you are behind. Be considerate of language barriers, and if you can, leverage a medical translation service during visits. This can be achieved by 3-way tele-conferencing, 3-way video conferencing, or having the patient on video and the translator on speaker phone. Regardless of the approach, consent should be obtained from the patient to use a translator and documented in the chart.

Some other tips for using virtual care in your practice:

  • For specialist referrals, consider using eConsult instead of sending a referral by fax. You can get a response from the specialist in about two days and sometimes within hours. eConsults also helps avoid unnecessary visits (in-person or virtual) for patients.
  • If your EMR allows for ‘stamps’, use them to prevent typing the same messaging repeatedly.
  • Doing group visits? Google Hangouts for psychotherapy or used with diabetes patients works well and is free. You can conduct a video call with up to 10 people. A virtual environment can work well when patients who do not like talking or leaving their homes see other patients with similar issues.

Virtual visits are not appropriate for all patients. You will want to see some patients in person during COVID-19. You and your staff should be in full PPE when you are in the office. Our clinician Peer Leaders recommend that you try to set up your schedule so that vulnerable patient populations (prenatal, well-baby, geriatric, immune-compromised) come in only during protected time slots so that the risk of exposure to potential COVID-19 patients is limited. For more information on virtual care and tools to consider and other useful resources, visit OntarioMD.News, . For questions about a specific tool on this site, please contact the vendor directly. If you have any general questions about using virtual care tools, please contact support@ontariomd.com