New Brunswick Virtual Care Action Plan

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Overview of areas of focus

Conversations about enhancing the offerings in relation to Virtual Care in NB have been occurring for years; however, the pandemic forced stakeholders in government and across the healthcare sector to accelerate the implementation of Virtual Care for basic primary care purposes to respond to the State of Emergency — limiting the movement of New Brunswickers within the province, closing businesses and promoting physical distancing. Virtual care solutions are significantly broader, more impactful, and more complex than typical, commonplace platforms such as Skype and Facetime.

Background

Connected Health has been identified as a critical offering with the potential to better enable access to care when the clinician and client are not in the same location. The notion of connected health also builds on the interaction between clients and/or members of their circle of care, occurring remotely, using any forms of communication or information exchange with the aim of maximizing the quality and effectiveness of client care. A key component to the Connected Health Program is Virtual Care.

Virtual Care has been defined as any non-face-to-face modality of care or supporting digital intervention.

The Virtual Care program was implemented across various sectors of the healthcare system as an access to care measure. A survey conducted by the New Brunswick Medical Society in May 2020 showed that 77% of respondents said they would support the continued use of Virtual Care by physicians and 9 out of 10 respondents who had received Virtual Care said they were satisfied with the experience.

Given the overwhelming level of support and interest by New Brunswick residents, the Department of Health is working closely with the Health Authorities to consider how to expand on a long-established Virtual Care Program. The vision for the Program is based on the goal of supporting appropriate use of digital health solutions keeping in mind the principles of client-centric, multidisciplinary, secure, and equitable access to care, long-term sustainability, and ease of use.

Objectives and priorities

Figure 1. New Brunswick Department of Health objectives
Figure 1. Text version below.
Figure 1 - Text description
  • Optimize population health and well-being
  • Provide quality, patient-centered care
  • Improve addictions and mental health outcomes
  • Improve the care and service experience of our seniors
  • Provide innovative care using digital technologies
  • Maintain and invest in facilities, technology, and equipment
  • Recruit and retain a qualified, accountable, health workforce

Delivering digital health for New Brunswick

Figure 2. Innovation and eHealth priorities
Figure 2. Text version below.
Figure 2 - Text description
  • Citizen-partnered: citizens as active members in health, access and coordination, optimize and collaborate, citizen centric
  • Sustainable: affordable, dependable, innovative, and efficient eHealth interventions. Digital by Design
  • Prevention: Enhance quality, health promotion, health protection, reactive/proactive learning health system (information as a resource)
  • Private and secure: citizens trust in the secure accessibility of their health data, secure and timely access to personal health information for providers and citizens
  • Data driven: measure and monitor, open and transparent, outcomes and benefits are tracked, accountable, citizen, policy, and decision makers are informed
  • Digital health pillars (technology as enabler): Citizen centric, access to care, unlocking clinical value

Work in progress

In New Brunswick, Telehealth programs have been in operation since 1998 and have been recognized for their successes. Additionally, Virtual Care has been used by a subset of family physicians for insured services since 2018 but the tools used thus far have been limited to onsite teleconferencing/videoconferencing equipment, telephone, and functionality specific to the Provincial Electronic Medical Record (EMR).

While conversations about enhancing the offerings in relation to Virtual Care in NB have been occurring for years, the COVID-19 pandemic forced stakeholders in government and across the healthcare sector to accelerate the implementation of Virtual Care for basic primary care purposes to respond to the State of Emergency that was declared in March, limiting the movement of New Brunswickers within the province, closing businesses and promoting physical distancing.

During the first year of the pandemic response the Department of Health, in collaboration with our health system partners undertook and expanded several virtual care initiatives.

Asynchronous Virtual Care

Asynchronous Virtual Care refers to communication (for the purpose of delivering patient care) which is not simultaneous or concurrent, such as a conversation through written means.

MyHealthNB

The MyHealthNB Program objective is to provide patients with secure access to their Personal Health Information. The initial scope was to include all lab results and medication profile. Due to the COVID-19 pandemic, MyHealthNB COVID-19 specific activities have been accelerated to allow those with a New Brunswick Medicare card to be able to securely access their COVID-19 test results online from their computer or mobile device.

The MyHealthNB COVID-19 Results solution includes a registration and identity verification process to establish a MyHealthNB digital account, and secure login to the COVID-19 Results application. Patients are able to view their negative, positive or equivocal result along with relevant instructions provided at the direction of Public Health.

The Department of Health Innovation and eHealthNB Services Branch (eHealthNB) and Service New Brunswick have launched this solution with the help of our vendor partners Simeio and VeroSource.

This is an important tool in our fight against COVID-19. By letting patients check their COVID-19 test results online securely, we are allowing healthcare workers to spend more time providing care for patients.

Provincial EMR Program

The Provincial EMR Program is a key part of achieving an integrated health system that unlocks clinical value for the clinicians and residents of New Brunswick.

The Government of New Brunswick has partnered with OntarioMD (OMD) to extend the OMD EMR Certification Program to support the Provincial EMR Program effective January 1, 2021. The OMD EMR Certification Program is Canada's longest established and most mature certification program and will accelerate the opening of the New Brunswick EMR market and minimize the work to vendors who already have a certified EMR offering in Ontario. 

Certified EMRs enable increased access to digital health systems for clinicians, including the Electronic Health Record (EHR) and lab results. This integration of digital systems improves patient care is an important step toward the goal of a more integrated health system.

The launch of the New Brunswick EMR Certification Program is a major milestone for the NB Provincial EMR Program. The move to an open market gives more EMR vendors the opportunity to expand their business in the province and gives clinicians more choice of certified EMR offerings, while maintaining confidence that the EMR product has been vetted for privacy, security and functionality.

The key objectives of the Provincial EMR Program are to:

Improve the efficacy of the health system through:

Improve clinical value of EMRs through:

Improve patient care outcomes through:

Personal Respiratory Management Record

Individuals with complex respiratory conditions are at an increased risk when any respiratory illness outbreak occurs. Complex respiratory conditions can also limit the communication abilities of these patients. With policies restricting access to health facilities for informal caregivers, there is an increased potential of contraindicated treatments in acute situations. The management of respiratory care equipment is complex and highly personalized.

Under the guidance of doctors and respiratory therapists from the Stan Cassidy Centre for Rehabilitation and the community, an online Respiratory Management Record was developed allowing patients and/or their care team to generate a personal Respiratory Management Record. This Record can be provided by the individual and/or their support person(s) to medical professions outside of their circle of care to support best care outcomes.

EReferral Single Entry Model Program

Wait times are one of the most serious issues facing healthcare in New Brunswick. The Provincial Surgical Advisory Group (PSAG), established in June 2020, identified 5 Priorities. Priority #1 is to Improve Access to Orthopaedic Surgery and Care, with a focus on the orthopaedic specialty (i.e. hip and knee joint replacements), and also includes the Improving Access to Specialist Care project. This initiative focuses on improving the patient's journey from the time a Specialist receives and accepts a referral from the patient's Primary Care Provider (PCP) to the time a patient is seen by the Specialist. This project includes the implementation of an eReferral Single Entry Model (SEM) Program to support the overall strategic direction of the healthcare system, with an overarching goal of improving citizen access to health services through streamlining access to Specialist care while ensuring the process is sustainable, patient focused and creates transparency for Specialists, Primary Care Providers and Patients.

The eReferral SEM Program initiative leverages a digital solution to facilitate a single entry point for the synchronization of health care service supply and demand, while facilitating the collection of accurate patient wait time data. This digital solution will:

With the implementation of a SEM program of pooled referrals, the consolidation of multiple waiting lists will rebalance wait-times between Medical Specialists, reducing adverse clinical outcomes for patients. A reduction in wait times will also lead to greater patient satisfaction, improved care, and confidence in the referral process.

Providers will benefit from the development of a standardized referral form and processes, supported through the implementation of a digital solution and single-entry model concept, ensuring Orthopaedic Specialists have the required information to triage and schedule the patient. This approach also provides Primary Care Providers with the ability to track the referral process as well as respond to patient inquiries, as they progress through the continuum. The implementation of an eReferral and SEM will also provide the ability to capture, monitor and report on desired wait time metrics (i.e. Wait 1 – time between referral from primary care to the first specialist appointment).

Upon completion of the Pilot, targeted for October 2022, the eReferral SEM program will be implemented in the remaining health zones to support referrals to the orthopaedic specialty province-wide. Future initiatives will also include integrating the eReferral digital solution with provincial EMRs to further optimize clinical workflows, for both PCPs and Specialists, in support of future expansion of the SEM program to include additional Specialties.

NB Virtual Care Mobile App

The NB Virtual Care Mobile App (available via Google Play Store and Apple App Store) includes an embedded secure file transfer feature which is specifically designed for clinical care and supports secure end-to-end file transfer and messaging to the patient and across the collaborative care team.

MBMD (Microblogging MD)

Horizon Health Network have invested heavily in MBMD (Microblogging MD) application which supports secure communications, image sharing, text, and notification/alert capability. This is currently deployed to support clinician to clinician consultation and can extend to the patient if desired or as part of a planned functional roadmap.

Zoom for Healthcare (ZoomHC)

ZoomHC includes an embedded solution for file transfer and asynchronous messaging which could be leveraged as an expansion to the current video-conferencing use cases for this technology.

Synchronous Virtual Care

Synchronous Virtual Care refers to communication (for the purpose of delivering patient care) which is in real-time, existing, or occurring at the same time, such as a telephone call or a video conference.

Zoom for Healthcare (ZoomHC)

ZoomHC is a secure, web-based virtual care video conferencing platform. Zoom is the leader in modern enterprise video communications, with an easy, reliable cloud platform for video and audio conferencing and collaboration across mobile devices, desktops and telephones. The Department of Health has obtained ZoomHC which provides additional security measures to protect the privacy of personal health information being shared over internet channels.

On 31 Mar 2020, the Department of Health signed a contract with Zoom to procure up to 7000 licenses for clinicians across NB. Following the completion of an abbreviated PIA and beta and pilot launches; the official roll-out of ZoomHC began 21 April 2020. By 30 May 2020, DH had received 1500 requests for ZoomHC licenses, in addition to Vitalité Health Network (VHN) and Extra-Mural Program (EMP) requests, totaling over 3300 requests for licenses.

As of November 2020, approximately 3642 ZoomHC requests were received with a utilization rate of approximately 65%. An estimated 10% of the New Brunswick population have received clinical care via ZoomHC.

The contract with Zoom is for 2 years. There is an opportunity to pool licenses with Horizon Health Network (HHN), whose NB Virtual Care platform uses a Zoom API for video-conferencing.

NB Virtual Care Platform

The NB Virtual Care Platform was developed by HHN to support the delivery of NB health care services by empowering the clinician and the patient to access HHN service from any internet capable device.

The NB Virtual Care Platform is a secure service that is supported by HHN staff and enables added functionality such as patient scheduling, virtual waiting rooms and patient tracking/reporting.

HHN has on-boarded 1195 users (Mental Health and Addictions, Primary Care/Community Health Centers, Cardiac Wellness, Nephrology, Oncology, and the Stan Cassidy Centre for Rehabilitation) to the NB Virtual Care platform, with 300 additional clinicians now qualified to also onboard to the Virtual Care platform.

Provisioning of iPads for nursing homes

The COVID-19 pandemic intensified the ongoing pressure on New Brunswick health services. The ongoing stress and strain of such an outbreak is felt most intensely by the most vulnerable populations in the province; including those individuals requiring care from NB Nursing Home Services. Residents of Nursing Homes in New Brunswick need medical care and are regularly seen by a Primary Care Provider (PCP) assigned to the home. PCPs typically care for residents during a present scheduled timeframe, referred to as "rounds", and on an ad-hoc basis when requested by a Healthcare Provider (HCP) at the home. During the COVID-19 pandemic, residents are vulnerable and are at risk due to their age, frailty and underlying medical conditions. With policies regarding the restricted access and prohibition of non-essential visitors and controlled access for staff, it is more important than ever to prevent and control transmission of the disease from essential visitors, including healthcare providers.

PCPs needed to assess and/or treat medical conditions as required, including the assessment of residents for COVID-19. To limit contact and facilitate a visit between a PCP and a resident, a "virtual" visit would allow for assessment and communication with the resident and a healthcare provider at the facility.

In conjunction with the Department of Social Development, approximately 400 iPads were deployed to nursing and memory care homes across the province. Use cases were identified for scheduled PCP "rounds" as well as ad hoc resident visits. Each iPad was provisioned with a ZoomHC account to support virtual visits as well as for contact between residents and their family/friends to mitigate social isolation.

In addition to these efforts, designated Healthcare Providers from approximately 80% of Nursing Homes in NB were given access to the provincial Electronic Health Record in order to provide digital access to the longitudinal view of their clients' health records. This has expedited access to crucial information including test results.

Virtual care outcomes

The Virtual Care program was implemented across various sectors of the healthcare system as an access to care measure. A survey conducted by the New Brunswick Medical Society in May 2020 showed that 77% of respondents said they would support the continued use of virtual care by physicians and 9 out of 10 respondents who had received virtual care said they were satisfied with the experience.

Given the overwhelming level of support and satisfaction by the province's residents, the Department of Health agreed to establish a permanent Virtual Care program, that:

Initiatives under the bilateral agreement

Building on past initiatives and lessons learned, the initiatives under the NB Virtual Care Bilateral Agreement will be omnichannel and patient centric. They will prioritize sustainability, appropriate and meaningful use, patient and provider experience, clinical value and measurable outcomes, and privacy and security.

The Virtual Care Priorities identified by the FPT Deputy Ministers in May 2020 are:

New Brunswick virtual care initiatives

New Brunswick's initiative will be focused on the following areas:

  1. Connected Health – Virtual Care Program
  2. Community-based care solutions

1. Connected Health – Virtual Care Program

The Connected Health initiative maximizes the quality and effectiveness of client care by facilitating remote interaction between clients and/or members of their circle of care. Flexibility and ease of use are coupled with robust security and privacy guidelines/reviews.

The program will look to establish policies supporting appropriate use, support provider education and patient choice, provision and/or outline omnichannel solutions, ensure equity of access.

New Brunswick has already begun work on a Virtual Care Playbook and has identified a few key initiatives to be included in this program:

Additionally, virtual care services help to support newcomers to the province through the use of translation services available in virtual care platforms. These initiatives will contribute to addressing some of the unique needs of under-represented populations and improve equitable access to care in the province.

New Brunswick will use the Virtual Care Bilateral Agreement funding to support:

2. Community-based care solutions

Provincial EMR Program

The EMR Open Market approach will consist of an EMR certification process that will identify a list of EMRs eligible to function in NB under the Provincial EMR umbrella. Certified EMRs will qualify for eHealthNB integrations as well as incentive programs targeted at increasing adoption and integration with the provincial health system - with the collective goal of improving patient outcomes and supporting clinicians in better delivery of care.

Community Care NB

Enhancing primary health care in communities across New Brunswick is an agreed upon strategy to improve the health care system. By providing the right community supports, health providers, integrated services and health information system, better health outcomes and citizen health experiences can be achieved.

An integrated digital health system is a key enabler for transforming community health. A few community health services have information systems but none of these systems are integrated and some are antiquated. By leveraging technology in the community, we can begin to shift from a reactive health care model to a preventative model connecting patients, providers and information across the health care continuum (community and acute care settings) and throughout the lifespan of the patient.

eReferral SEM Program

The eReferral program will implement a pilot for non-urgent referrals to Zone 3 and Zone 6 Orthopedic Specialists. This program will streamline access to Orthopedic Specialist care in addition to capturing and tracking the patient journey through their wait time to specialist consultation.

The eReferral solution will be embedded within the provincial EHR, and will support a central intake/SEM process for orthopedic referrals from Primary Care Physicians and Nurse Practitioners. These clinicians will submit electronic referrals to Orthopedic Specialists from both Regional Health Authorities.

New Brunswick will use the Virtual Care Bilateral Agreement funding to support:

Funding allocation table

Funding allocation table
Total federal funding to New Brunswick $5,293,948.00
  2020-21 2021-22 Total VC Bilateral
Connected Health – Virtual Care Program $251,880 $349,351 $601,241
Community-based care solutions $2,513,251 $2,179,456 $4,692,707
 
Total per fiscal year $2,765,141 $2,528,807 $5,293,948

Performance measurement and expected results

A benefits evaluation with metrics will be developed for each of the areas identified in the NB Virtual Care Bilateral Agreement.

Connected Health: Virtual Care Program

NB will work with CHI to define a set of pan-Canadian indicators that will be used by the Canadian Institute for Health Information (CIHI) to standardize and measure progress on virtual care implementation across Canada. Aligned with work in progress, New Brunswick will develop a Virtual Care Program which includes adoption and outcome measures.

Virtual Care Program measurements will build on the initial reporting to collect data on usage, patient satisfaction, provider satisfaction.

Community-based care solutions

As the province implements an EMR Open Market and Community Care NB solution, information to track and evaluate the implementation of the solution(s) is very important to the sustainability of the program. It is also important to understand the impact of an EMR solution on the health care system, including its effect on patient data reporting and quality of patient care.

The anticipated benefits of implementing the Community Care NB Solution in the community include: increased patient care time and efficiencies; improved quality of care provided to patients through real-time access to patient information for decision-making; improved clinician experience; and, maintaining a high overall patient satisfaction through the coordination of services

Utilization of the EHR is expected to increase with the addition of clinical documents. The EHR business team tracks utilization numbers on an ongoing basis and will compare pre and post implementation numbers.

Wait time will be the primary indicator measured in the eReferral SEM Program. It is anticipated the wait times will reduce and patient satisfaction and well-being will increase.

Summary of jurisdiction-specific indicators and expected results
Initiatives Outputs Target outcome
Connected Health: Virtual Care Program
  • Pan-Canadian - collaborate on the development of indicators with CIHI and report
  • New Brunswick – complete virtual care program and develop indicators to measure:
    • Uptake
    • Quality (e.g. provider and patient satisfaction via surveys/interviews)
    • Patient safety
    • Appropriateness (inc. avoided unnecessary in-person care)
  • Access to omnichannel health care interventions
  • Patient experience and satisfaction
  • Adoption in Nursing Homes / Adult Residential Facilities
  • No show rates
  • Wait times
  • Provider / staff experience and satisfaction
  • Adoption Rates
  • Usage of tools and programs
  • Demonstrate that virtual care is care and an omnichannel connected health care model can improve access and equity, safety, and patient and provider experience
  • Demonstrate improvements to efficiency of the health system
  • Demonstrate increased adoptions across patient populations
  • Demonstrate positive patient experience with virtual care tools and programs
  • Demonstrate positive provider/staff experience with virtual care tools and programs
Community-based care solutions
  • Adoption
  • Expansion of Open Market
  • Adoption and evaluation management tool
  • Program Monitoring
  • Program Evaluation
  • Real-time access to information to support decision making
  • Increase and more efficient use of tools for virtual visits
  • Increase in patient satisfaction
  • Information on patient outcomes is readily available at both the individual and aggregate level
  • EHR Utilization numbers
  • Surgical Wait times (Wait 1)
  • 2 certified EMRs in NB open market by 2022
  • 4 certified EMRs in NB open market within 5 years
  • Development of an adoption and evaluation management tool providing information to track program progress, improve program, report to stakeholders, and provide information for decision-making on programmatic resource distribution throughout the health system
  • Increase patient care time and efficiencies
  • Maintain high overall patient satisfaction while improving satisfaction with coordination of services
  • Improve quality of care provided to patients through real-time access to patient information for decision-making
  • Increase in clinician usage of EHR
  • Decrease in average Wait 1 time for Orthopaedic Surgery and Care
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