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. 

Keeping our Patients Safe: Prescribing in the Digital Era

This post was originally published in Quorum on August 17th, 2017.    

According to a recent study, poison control centres in the US receive a call about medication errors every 13 seconds, and that rate has doubled in the past 12 years (1). Doctors, nurses and nurse-practitioners prescribe medications (and more recently focus on de-prescribing many drugs) on a daily basis, largely without a second thought. These medicines change the lives of our patients every day – often for the better, but unfortunately sometimes for the worse. Given the power of drugs and the authority we wield every time we sign our name to a prescription, it’s important that we do everything we can to focus on safety and effectiveness.

Most prescribers become familiar enough with a handful of different medicines to confidently prescribe them without risk. But sometimes we introduce a distinct cognitive bias by extending our comfort level with one set of drugs to others, including rare, unfamiliar and dangerous ones. It is impossible for any human being to remember all the details of side effects and interactions for the thousands of medications we are thought to be experts on when we prescribe. Add in the notion that individual genetics dictate the way or bodies consume and dispose of medications, and it’s easy to see how this overconfidence and generalization can have dramatic consequences for patients.

Fortunately, there are systems and processes in place that lower our risk of error dramatically. Computerized provider order entry applications like e-prescribing involve electronic entry and transmission of medical orders, and have been found to reduce medication error rates by over 50%.(2)The EMRs used by most community-based physicians in Canada have built-in interaction checkers that compare not only drug-to-drug interactions, but also drug-to-disease-state interactions. And they will alert us when a potential problem arises – assuming we are using the most current version of our EMR and drug database, and have not turned off alert capabilities due to information overload.

While we certainly don’t want our prescription modules to alert us incessantly, we do need to understand the likelihood of severe interactions every time we prescribe. Reminder alerts can also be set up in the EMR for therapeutic monitoring, which is frequently forgotten when prescribing titrated drugs like lithium or anti-seizure meds. It may also be worthwhile to incorporate alerts regarding Beers List drugs that should never be prescribed to elderly patients.

Of course, these types of alerts are only as reliable as the accuracy of the patient information and medication lists in our EMR. So, it’s important for every provider to take the time needed to update medication lists at every patient visit, whether or not it’s considered our direct responsibility to do so.

Tools like EMR, CPOE and automated alerts represent the tipping point in our ability to avoid medication errors using digital health. But there’s more on the horizon. Integration of province-wide databases such as the Digital Health Drug Repository, Digital Health Immunization Repository and Narcotics Monitoring System through the ConnectingOntario and Clinical Connect viewers will be a huge leap forward, giving us the ability to review medications prescribed and dispensed from all practitioners involved in a patient’s care. Integrating this information into EMR prescribing modules will have an even greater impact.

The ability to quickly view and analyze data across our entire patient roster will soon be possible for all using the OntarioMD EMR dashboard.. Work being done on the EMR dashboard – in partnership with Health Quality Ontario, the Ontario College of Family Physicians, the Association of Family Health Teams of Ontario, Association of Ontario Health Centres and the College of Physicians and Surgeons of Ontario – will make it easier to track drugs of interest among our own patients, and will provide a practice-wide population health perspective. This becomes imperative when considering high risk prescribing scenarios like narcotics doses above 50 morphine mg equivalents per day, in immunocompromised patients, and for those on multiple medications with more than one complex chronic disease.

Important digital tools, combined with appropriate policy, education and advice on how to cautiously prescribe and monitor risky drugs, have the potential to help us stave off adverse reactions, overdoses and even deaths. But we must also focus on ensuring that we understand new prescribing guidelines, screen for misuse, employ narcotics contracts and periodically review long-term medication use with patients as diligently as we analyze new drug starts.

With the privilege of prescribing comes great responsibility. Thinking about prescribing safely at the point of care and asking ourselves if we’ve taken advantage of every tool available to make this work easier will give us the best chance we have in doing the right thing for our patients, our practices and ourselves.

  1. Nichole L. Hodges, Henry A. Spiller, Marcel J. Casavant, Thiphalak Chounthirath, Gary A. Smith. Non-health care facility medication errors resulting in serious medical outcomes. Clinical Toxicology, 2017; 1 DOI: 10.1080/15563650.2017.1337908
  2. Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic Reviews. 2014;3:56. DOI: 10.1186/2046-4053-3-56.