Virtual care and health technology assessment considerations

Virtual care

Prior to the COVID-19 pandemic, virtual care, namely, clinician visits and diagnostics, was not commonplace. Six percent of Canadians had received at least one virtual care service prior to the pandemic. ¹ The relatively limited uptake of virtual care may have been due to uncertainties and perceived barriers including issues about access, privacy and security, billing, safety, and scope of practice, in addition to its potential to cause disruptive change. ² When COVID-19 emerged as a global public health emergency in early 2020, many aspects of how we deliver healthcare were forced to change almost overnight. By fall of 2020, 56% of patients in Canada had received at least one virtual care service. ¹ Bhatia and colleagues (2021) reported that ambulatory virtual care visits in Ontario increased from 1.6% in 2019 compared with 70.6% in 2020. ³ Some virtual care options existed prior to the pandemic, but they were typically minimal in scope and used only in specific situations such as mental illness, chronic obstructive pulmonary disease, heart failure, asthma, hypertension, angina, and diabetes as examples.^3,4

As we move toward the future of integrated virtual technologies, we will likely see technologies with broader functionality, enhancements, and availability. Virtual care technologies will need to show value to the health system as we move into a post-pandemic stage. Value of these technologies can be evaluated by Health Technology Assessments (HTAs).

Health technology assessment

Health technology assessment determines the value of health technologies by using explicit methods and a multidisciplinary process. ⁵ CADTH is an HTA organization that provides Canada’s healthcare decision-makers with objective, unbiased evidence about the optimal use of health technologies. CADTH’s HTAs include one or more components: clinical effectiveness, cost-effectiveness, patient perspectives and experiences, ethics, implementation considerations (operational aspects), legal issues, and environmental considerations. CADTH tailors its HTAs to include only the components necessary to inform the specific decision to be made.

HTA of virtual care: Pre-pandemic

Before the pandemic, virtual care HTAs typically examined specific interventions for individual indications. CADTH and Health Quality Ontario (now Ontario Health) published an HTA of Internet-delivered Cognitive Behavioural Therapy (iCBT) for major depressive disorder or anxiety disorders. This virtual care technology was compared with in-person care and wait list for in-person care for those specific indications.^6,7 The components of the HTA of particular relevance for the recommendations were clinical effectiveness, cost-effectiveness, patient perspectives and experiences, implementation considerations, and ethics.^6,7 Internet-delivered cognitive behavioural therapy was found to be more effective than wait list and was acceptable to patients, for patients with mild to moderate major depressive disorder or anxiety disorders. ⁸ The results of this HTA informed decisions prior to the adoption of the technology. This timing differed from the pandemic experience when virtual care was adopted rapidly without HTA.

Virtual care and the COVID-19 pandemic

Out of necessity, virtual care was adopted rapidly during the pandemic, precluding the ability for HTAs to inform decisions about the adoption and optimal use. The rapid and widespread implementation of various forms of virtual care did, incidentally, shine a light on the many potential benefits of a more virtually based healthcare system moving forward. Examples of these potential benefits include (but are not limited to):

1. Improved access to healthcare for patients—particularly those living in more rural or remote locations, or who may have other barriers to accessing healthcare in person.

HTA of virtual care: Pandemic response

Health technology assessment components required to address issues related to virtual care during the pandemic shifted. Since virtual care was often the only option during the pandemic, clinical effectiveness and cost-effectiveness compared with in-person care was not questioned. The questions for HTA were about the best way to implement virtual care to continue to provide healthcare during the pandemic, including implementation considerations and patient perspectives and experiences. ¹⁰

As we move forward in a post-pandemic world, HTA questions on virtual technologies adopted during the pandemic may include not just whether they work but will likely include analyses on what medical conditions would be suitable for virtual care as compared to in-person care. Other questions could investigate the value of new virtual technologies by considering relative value among other virtual technologies, value to different stakeholders (eg, health system, patients, and society), value of different modes of communication, understanding priorities around equity of access and digital security, and acceptability of different technologies.

Importantly, as the healthcare landscape evolves to include greater consideration of virtual care options, the work of HTA agencies will need to reflect this. Specifically, the mode of delivery of healthcare services will need to become a central consideration for HTA. While HTAs on virtual care have not been conducted widely, CADTH conducted an HTA on Remote Monitoring (RM) programs for cardiac conditions (heart failure, atrial fibrillation, hypertension, and cardiac rehabilitation). RM is a type of telehealth where healthcare is delivered to patients outside traditional settings by allowing health data to be exchanged between patients and healthcare providers using telecommunication technologies or stand-alone devices. Considerations associated with virtual and remote technologies across a variety of conditions in a technology agnostic approach were assessed. ¹⁰ This HTA took a unique approach and assessed how RM programs for cardiac conditions can work most effectively by conducting a realist review. The HTA also included patient perspectives and experiences review and an ethical analysis. Notably, the HTA did not include an assessment of clinical effectiveness; rather, the non-clinical questions about who remote monitoring works for and in what context were the emphasis. It is anticipated that HTAs of this nature will become more prevalent in post-pandemic times.

Emerging virtual care technologies

An additional consideration throughout the pandemic was the need to identify emerging technologies in anticipation of decision-making needs. Through the application of horizon scanning (a process that involves systematically summarizing evidence on emerging technologies that are not yet in widespread use across the country ¹¹ ), topics such as virtual waiting rooms, connected devices to support remote clinical examination of patients, smartphone apps to support contact tracing, wearable devices to monitor COVID-19 symptoms, and at-home testing for SARS-CoV-2 were addressed prior to immediate decision-making needs.^12-16

Early identification and reviews of technologies with emerging and uncertain impacts on the healthcare system also provides HTA organizations with the opportunity to explore early evidence. Horizon scanning in the virtual care space has highlighted the importance (and current limitations) of operational considerations of these technologies such as remuneration practices, inter-jurisdictional licensure, equitable and affordable access to care, data privacy and security, and appropriate patient selection.^13,15,17 The continued scanning for emerging technologies in the digital health and virtual care space will enable us to prepare and assess the potential impact on the healthcare system, as well as monitor the evidence base for HTAs when adoption decisions are imminent.

The COVID-19 pandemic has provided an opportunity to assess the value of virtual care, and virtual solutions may reduce health system costs and unnecessary services, enhancing health system sustainability. ¹⁸ An additional consideration for HTA organizations moving forward will be the type of evidence that is most useful in the evolving landscape of virtual care. The evidence needs for HTAs on virtual care technologies may be complex and differ from the type of evidence traditionally included in HTAs. More specifically, if the research questions that are of importance to decision-makers do not lend themselves to randomized controlled trial data, there may be greater utility in considering other types of evidence such as real-world evidence and qualitative evidence. It will also be important to consider operational aspects (such as training requirements and internet access), ethical and legal considerations (such as equity, data ownership, and privacy), patient and clinical perspectives and experiences (such as modality of choice [phone and video] and time saved from travel to receive in person care), and environmental considerations (such as carbon emissions savings) in the assessment of virtual care and digital health technologies moving forward.

Conclusions

The rapid and widespread implementation of virtual care to assess and triage patients and to provide ongoing regular care where possible profoundly shifted the healthcare landscape. Virtual care offered a temporary solution for healthcare during the pandemic, and it demonstrated the promise and feasibility of implementing virtual care in a post-pandemic environment.

As virtual care evolves, HTAs evaluating virtual care and digital health technologies must evolve as well. It will be necessary to assess which HTA components are of greatest relevance for decisions being made about the use of virtual care services and technologies. Health technology assessment organizations should work with decision-makers to understand the issues that virtual care technologies are intended to address. Health technology assessment organizations can then evaluate the main drivers (components) in the HTA. Recognizing that clinical effectiveness may not be the most relevant driver for decision-making and ensuring flexibility to focus efforts on the most relevant components, such as patient (and caregiver) perspectives and experiences will be key.

Finally, continuing to monitor the landscape for emerging virtual care technologies through horizon scanning will prepare HTA organizations and healthcare decision-makers. Horizon scanning will allow HTA organizations to proactively assess information on emerging virtual care technologies to support decisions on the use of virtual care in the future.