Abstract
Banking, transportation, and retail have each been transformed by technology enabling on-demand access 24/7 at lower prices. This trend has not yet revolutionized the medical field, but on-line physician services are increasingly common in Canada and have the potential to change the way care is delivered. In this article, we will describe the state of on-line physician services in Canada and outline associated ethical considerations, including autonomy, beneficence, maleficence, and justice. We will suggest steps to mitigate risk so that these services add value for patients and the health system as a whole.
Introduction
Communication technologies for physician-to-physician and patient-to-physician communication can be classified as asynchronous (mail, e-mail, or voice mail messages) or synchronous (videophone, telephone, or instant message). Synchronous communication has been used for patient-physician consultations in certain settings since the 1970s, typically offered by a family physician to their patients, for specialist consultations in remote areas, or for patients who have mobility barriers. Only recently in Canada has there been on-line medical services that allow any patient to initiate a consultation with a family doctor, who is not their usual physician, using synchronous communication. Some services charge a fee to the patient, while others rely solely on billing provincial healthcare plans. Each offers assessment of minor uncomplicated medical concerns including prescription refills of non-controlled substances by telephone, videophone, or instant message, 24 hours a day 7 days a week, often with premiums charged after hours.
Accessibility
Accessibility is a core principle of the Canada Health Act and requires that all insured persons have reasonable access to services, unimpeded by user fees or discrimination. 1 Within Canada, Geographic barriers, due to the size of our country, and human resource shortages in some areas challenge our ability to provide equal access. Aside from system issues that limit access, many patients have physical disabilities or mental health barriers that decrease access for those who need it most. Although considerable costs are incurred to address these barriers, equity of access remains an aspirational goal. 2 Embedded within the core concept of the Canada Health Act is the ethical principle justice—or ensuring equal access irrespective of means.
On-line medical services have potential to improve access for people who experience barriers to face-to-face physician consultations. There are many reasons why patients may not be able to receive in-person care at a clinic. These include lack of availability of practitioners, distance to travel to care providers, disabilities limiting transportation opportunities, and a mismatch between when patients can go to a clinic and clinic operations. On-line services might even be preferred by some patients as being more convenient. On-line services not only improve justice but also address patient autonomy by increasing the number of choices for services.
Evidence
What does the evidence tell us? Several small studies have shown that patients like the convenience of on-line medical services but improvement in equity and access has not yet been shown. 3,4 Counterintuitively, access to on-line medical services has the potential to increase inequity as has been seen with other public health interventions. 5 People who are technologically literate, speak one of Canada’s official languages, have access to a device, and have a private place to use it will be most likely to access medical services on-line. 6,7 Conversely, older people with lower socioeconomic status who already have barriers to care will likely have reduced access to on-line medical services. Some on-line medical services are pay-for-use, which exacerbates concerns that on-line medical services will worsen inequity. Thus, while there are reasons to believe on-line services increase justice and autonomy, the evidence is inconsistent.
Pay-for-use care offered by some on-line medical services violates the Canada Health Act principles of comprehensiveness and accessibility that state all necessary health services must be covered by the provinces and physicians may not receive compensation above what is provided by the province. Those running the pay-for-use services argue that on-line visits are not currently covered by provincial health plans and therefore have not yet been deemed necessary health services. Charging patients for non-necessary services does not violate the Health Act. The logic here may be flawed because an on-line visit offers the same service as an office visit and differs only in how the patient interacts with the physician. Some on-line medical services are, in fact, billing provincial health plans for their services as if on-line visits are the same as office visits. These inconsistencies have not been addressed and are barriers to broader adoption of the technologies.
The ethical principles of beneficence and maleficence are also very important. As mentioned, the benefits have been poorly proven and there are potential harms. In their current form, on-line medical services are not integrated into the health system. This may contribute to existing problems with fragmented care and information discontinuity. Although difficult to measure, the patient-physician relationship has diagnostic and therapeutic benefit. 8 Understanding what symptoms are typical for a patient can help a physician determine the difference between benign and serious pathologies and a patient may disclose more details to a physician they know well. A study of family physicians found that sustained continuity of care prevented emergency department visits and improved preventative care. 9 If on-line doctors are primarily offering consultation services to patients they do not know, then on-line physicians will contribute to fragmented care, offering poor value to the health system. Furthermore, fragmentation may lead to missed opportunities for preventative care such as smoking cessation counselling when seeing a patient for a respiratory tract infection. In contrast, continuity of care may improve compliance with treatment plans by fostering shared decision-making and increasing engagement in care and trust in the diagnosis and plan of treatment.
Access to a shared medical record can reduce fragmentation when a physician is seeing a patient they do not know. The medical record provides an understanding of previous medical history and allows communication with other providers in the circle of care. Currently, on-line medical services in Canada do not have access to a shared medical record and there is no obligation to communicate with the patients’ usual primary care physician. A physician seeing a patient at a virtual visit cannot contribute to a shared understanding of the patients’ health. Instead they are working in isolation not knowing the patient’s history and unable to contribute to the overall plan of care. Not knowing a patients’ history can lead to incorrect diagnoses. For example, symptoms of cough and shortness of breath will be interpreted very differently if a patient has a history of heart failure or asthma. Accurately communicating all relevant past medical history during a single visit is difficult especially for patients with multiple chronic diseases.
Privacy and confidentiality
There are concerns about privacy and confidentiality when sharing health information with a physician over the Internet. These concerns are greater still if a patient is able to grant access to a centralized on-line health record with all of their health information. Addressing these issues is an ongoing technical challenge in the quickly changing world of information technology (IT) security.
On-line medical services are not appropriate for life-threatening or complex issues. Even though on-line medical consultations are relatively new, telephone triage systems that offer medical advice are not. Numerous provinces have telemedicine services where a patient can speak to a trained nurse about their symptoms 24/7. These systems rely on trained medical staff to triage patients with heart attacks, strokes, and other medical emergencies to the appropriate medical services while advising a more conservative approach for patients with non-urgent complaints. On-line medical services are no different. Safety is unlikely to be an issue with pre-visit checklists to book an appointment and physicians appropriately triaging patients to either face-to-face visits or emergency visits as needed. 10
In summary, while on-line services have positive theoretical ethical impacts related to justice (by increasing equitable access), autonomy (by increasing choice), and beneficence (by improving timely access), there are also concerns the technologies could negatively affect maleficence (by increasing care fragmentation). Although the negative concerns exist, these are likely not innate features of on-line technologies, instead these risks result from poor integration and coordination within the health system. Synchronous communication technologies will likely transform our health system by improving access and reducing costs if they are integrated into existing health system infrastructure. A critical consideration, therefore, is how they are implemented.
Educating the public on how and why they should access an on-line doctor will be critical to maximize benefit and minimize potential harms. A public health campaign targeting people with barriers to access may help to mitigate inequity concerns with this new technology. If on-line medical services are offered through family doctor’s offices, then each clinic could offer educational materials describing the circumstances under which an on-line visit could replace an office visit. Education on how to use on-line medical services could be integrated into other public health efforts to increase health literacy and patient’s engagement in their own care.
The future
Imagine a patient whose family doctor uses synchronous communication technologies. The patient has had a cough and sore throat for 3 days and decides to instant message the clinic requesting advice. A standardized questionnaire for red flag symptoms related to upper respiratory tract infection is immediately sent to the patient along with some patient education resources targeted to the patient’s health literacy as documented in their medical record. When the patient is unsure about one of the red flag symptoms, a more extensive standardized symptom assessment form is sent to the patient along with a videophone appointment time later that afternoon. Just prior to the call, the physician reviews the patients’ medical record, the symptom assessment, and the vital signs uploaded from the patients’ smart watch. Armed with knowledge of the patients’ history, symptoms, and vital signs, the video-call quickly clarifies the symptom in question and reassures the patient that symptomatic treatment is sufficient for now.
How can we make this future possible? Technology will undoubtedly transform healthcare delivery and safety, but without care, thought, and planning, on-line medical services in Canada currently have the potential to worsen inequity and further fragment care. These risks are not part of the technology itself but instead are a result of stand-alone consultations, initiated by patients using technology that is not equally accessible. Aligning on-line medical services with the Canada Health Act and determining reimbursement approaches consistent with it are critical to ensure these technologies help rather than exacerbate equity in health system access. Providers need to incorporate new technologies to ensure continuity of care integrated with in a shared medical record. Finally, prior to system-wide adoption, new technologies should be evaluated to ensure value and explore possible unintended consequences. By following this advice, we can ensure the promises of these technologies are realized.