A Message from the Editor-in-Chief

The theme of this edition is virtual care. We were fortunate to have an inordinately large number of submissions so we chose to include articles that are related, timely and important as we emerge from the COVID-19 pandemic. The authors have emphasized the importance and necessity of digital technology in providing support during the pandemic, but they have also reminded us that we must be mindful of unforeseen negative consequences of virtual care. Virtual care has proven invaluable during the pandemic; however, face-to-face interaction is essential to maintain quality healthcare outcomes for patients and providers. The papers in this edition provide some valuable insights on gaps and unmet needs that have been exposed by the pandemic as well as lessons learned on how to sustain improvements more effectively into the future.

Brit Cooper-Jones et al. point out that Health Technology Assessment (HTA) prior to the pandemic focused on the clinical and cost effectiveness of virtual care to inform decisions on the optimal use of the digital technology. The pandemic elicited an urgent response for virtual technologies to fill the gap in the care delivery process. This mobilized HTA to shift their focus to the effective and efficient post adoption and implementation of virtual technologies. The urgency stimulated HTA to pivot toward issues such as what technologies are appropriate and available for what medical conditions? How can effective consultation be facilitated? How can equity of access to service be achieved? What and how is remuneration for services to be handled? The authors encourage healthcare providers, leaders, policy makers and health technology agencies to learn from the lessons of the pandemic and to stimulate, accelerate and sustain the assessment of new virtual care technologies through their entire life cycle with a view to enhancing the quality of the patient care experience.

The pandemic has shone a light on the disproportionate distribution of morbidity and mortality among racialized populations in our society. Clara Lu et al. conducted a retrospective cross-sectional study to determine the proportion of patients, representative of their racial or ethnic identity who are admitted to hospital with and without COVID-19. From the samples they studied, the researchers identified that ethnicity assessments were recorded among only 44% of COVID-19 patients and 49% in the reference group. The authors caution that if less than 50% of inpatients in their sample are not having their ethnic and racial data collected, it will make it difficult to study and remedy racial health disparities in policy and healthcare provider settings. This should be a significant concern if the lack of data creates a bias in respect to social characteristics that are integrated in artificial intelligence systems and those are used to make resource allocation decisions that further marginalizes subpopulations. The authors advise on the need for diligence in the recording of ethnicity assessments.

The emergence and accelerated development of digital health care technologies in support of patients, providers and citizens during the COVID-19 pandemic has magnified the digital divide between the citizen and the healthcare system. As a case in point, Borycki and Kushniruk point to the emergence of health and wellness digital technologies that allow patients to be consulted, monitored, and assessed in home settings to encourage aging in place. The authors identify many of the challenges associated with implementing an effective virtual model of care where there is a seamless ability to access and share health information. The authors call for the development and adoption of innovative models that will promote effective and sustainable virtual care. They call for a convergence and integration of the personal digital ecosystem of the patient and citizen in their home setting with the institutional healthcare delivery sectors such as hospitals and primary care clinics.

Sadri and Sadri turn our attention toward rethinking how society may respond to the rising numbers and unmet needs of Older Adults (OAs) in Ontario whose number are expected to double in the next 20 years. Recent data from multiple sources emphasizes that residential Long-Term Care (LTC) is not the preferred choice of many OAs. The authors point out that many countries have implemented LTC models that promote independent home/community living rather than institutional residential care. Comparisons with peer OECD countries illustrate that many allocate 80% of their funding for LTC toward home and community funding and only 20% toward residential LTC. In Canada it is the opposite. The authors encourage readers and policy makers to think about alternative delivery methods to address the needs of OAs funded through a mandatory public LTC insurance policy that includes care at home/community setting.

The state of primary care in Canada is under resourced, fragmented, and inaccessible to as many as 15% of Canadians. Rowland focuses our attention to the important role of nursing to facilitate seamless transitions to and from primary care for those patients with chronic conditions and multiple complex needs. Rowland describes the Edmonton Southside Primary Care Network (ESPCN) process for nurses to ensure timely hospital post-discharge follow-up calls and physician appointments. Of key importance in these interfaces is the assessment of readmission risk using the LACE index and Clinical Frailty scores. Rowland’s data demonstrates that the ESPCN readmission rates and Family Practice Specific Conditions were significantly lower than comparator groups without the intervention. Supportive nursing involvement with consistent processes are a key ingredient to enabling primary care teams to support their highest risk patients from experiencing adverse outcomes and accessing the most appropriate setting for their care.

COVID-19 has accelerated the global uptake of telemedicine modalities. Xie et al. anticipate that the permanent integration of telemedicine will lead to numerous challenges that require innovative solutions and further research. The authors examined the publication trends on telemedicine over a 45-year period and the number of publications by Canadian researchers increased from 1 per year in 1976 to 80 per year in 2020. The research publications focused on primary care, COVID-19, telepsychiatry, heart failure and mental health. The authors contend that an improved understanding by stakeholders of the current telemedicine landscape of the challenges and issues will help develop national strategies and stimulate future research.

Liu and Cruz provide an overview of the effects of the COVID-19 pandemic on the adoption and diffusion of digital technologies, for example, healthcare devices and consumer products. The authors demonstrate that the diffusion has been rapid and dramatic even though it may not have always been voluntary. The authors review several technology adoption models identifying the characteristics, variables and conditions of diffusion that must be met for successful uptake to occur. Practical experiences and challenges during the uptake of digital technology in response to the pandemic are highlighted. The authors encourage leaders, providers and policy makers to propel the diffusion of innovative and effective home monitoring technologies that will serve patients with chronic health conditions including those with post-COVID syndrome.

Yun et al. describe a unique program identifying a peer-leader champion to act as a change agent to implement large scale quality improvement initiatives at Alberta Health Services. The Collaborative Care Framework (CoACT) recognizes that staff resistance is often a barrier to implementing evidence of effective practice. The authors describe how CoACT has empowered the champions, who are part of the healthcare delivery team, to foster continuing education, facilitate implementation activities, and participate in a community of practice. Structured around the CCHL LEADS framework the program has demonstrated a positive influence on career advancement.

The rapid escalation in the use of teleconsultation during the pandemic stimulated Myronuk to explore the possibilities of the widespread use of teleconsultation contributing to healthcare providers experience with mental fatigue. Myronuk draws on the experience outside of healthcare and in telepsychiatry where attention to non-verbal communication and sustaining empathetic rapport requires increased cognitive effort leaving the healthcare provider more sensitive to cumulative fatigue effects. Health leaders and policy makers are encouraged to think about and plan on how videoconferencing can be integrated into healthcare delivery without unintended negative consequences on provider experience and burnout.

Docherty and Richard describe how, faced with the pandemic restrictions, they modified a 2-week in-person orientation for six Urgent Primary Care Centres on the theme of Team Based Care (TBC) through a self-directed on-line delivery medium. The authors used this unique opportunity to pivot to an insider, action-oriented approach to systematically lead practice changes and build their expertise in TBC implementation. They relied on the application of complexity science to managing change and the synthesis of their TBC framework. The authors describe their experiences and lessons learned not as a destination to be arrived at but rather a continual journey for PCC teams to build shared goals within a TBC ecosystem.

Jassar et al. address the promising opportunities arising from the application AI in healthcare. The authors identify the potential new risks that emerge from the technology itself and how it redefines the nature of physician involvement and their relationship to their patients. The paper describes the current legal landscape of the clinical use of AI in Canada, identifies limitations as novel uses of AI emerge, provides examples of international guidance that is emerging, and encourages professional bodies to help promote the appropriate and safe use of clinical AI. Healthcare providers and leaders will need to be prudent and engage in discussions and formalization of the evolving medical-legal context for the future of AI in clinical practice and healthcare delivery.